Catheterization from the Wrist Taking Over

Just recently, cardiac catheterization from the wrist, or transradial cardiac catheterization, was featured on the Dr. Oz show and immediately we were fielding questions about it in the office and reading about it on the blogs.

Now, even more impactful, was the recent recommendation from the European Society of Cardiology that the radial approach should be considered as the first-line access site:

“The radial approach for percutaneous coronary interventions (PCI) was developed 20 years ago and is used for more than 50% of procedures in France, Scandinavian countries, the UK, Spain and Italy. Despite the advantages of radial access some countries in Europe such as Germany use radial access for fewer than 10% of PCI….

“Evidence has accumulated in the literature showing the benefits of radial over femoral access for PCI including reduced bleeding and improved survival. In addition, the development of smaller and thinner devices has made the radial approach increasingly practical.”

For most of us in the interventional cardiology world, the radial approach has been slowly gaining traction over the past 5 years in the US. As of 2007, less than 2% of all coronary stent procedures were done from the wrist but in 2012, according to the National Cardiovascular Data Registry (NCDR) more than 11%  were done radial style.

Patient safety and comfort are always a concern to physicians and the radial approach has shown superiority to the femoral (groin) approach in both categories. In terms of safety, numerous studies have shown significantly less bleeding complications as compared with the femoral approach. This is in large part due to the fact that unlike the radial artery, which is bordered by bone and connective tissue, the femoral artery lies right next to a large caliber femoral vein and complications can be difficult to identify at first because of the large potential space for blood to go, i.e. the thigh or abdomen. Women are actually at higher risk of groin complications from cardiac cath and currently Dr. Safirstein is the Principle Investigator of SAFE-PCI, a multicenter, randomized control trial looking at the benefits of the radial approach in women, run in collaboration with more than 25 of the best coronary centers of excellence across the US.

Comparing comfort of the 2 techniques, it is not hard to see why patients have preferred radial more than 90% of the time. Cath from the wrist allows patients to sit up immediately after the procedure (even when a stent is placed) with a pressure dressing over the small puncture site on the wrist. The femoral approach demands anywhere from 4-8 hours of lying flat so as not to disrupt the clot that forms over the femoral puncture site. This becomes particularly relevant in patients who have back pain issues or cannot lie flat for any reason.

From a cost standpoint, less complications mean less money spent on follow-up imaging studies, blood products that might be required, consults with other specialists, and of course, length of stay. The radial approach has been shown to save both hospitals and patients money and time in the hospital.

Drs. Safirstein and Fusman both are proficient in radial cath and Dr. Safirstein served as the Director of Transradial Intervention at Morristown Medical Center. Later this year, he will be Course Director for the annual Mid-Atlantic Radial Symposium (MARS2013), hosting world-renowned experts who will educate both physicians and cath lab staff from NY/NJ/PA on everything transradial!

Home Blood Pressure Monitoring: Who, Why and How

More and more, our patients are becoming proactive about their health and increased access to affordable, reliable and portable home health tools like glucometers and blood pressure monitors only makes the doctors' job easier. Sort of. If done correctly, these tools can be an invaluable asset to your physician and your health. However, when they are done at inappropriate times or done incorrectly they can adversely affect the way you are treated and cause more harm than good.

Why is home monitoring important?

Going to your scheduled doctors' appointments and having your BP checked is indeed a necessary and important feature of your healthcare but it is only one snapshot of your blood pressure. Our circulatory systems are not a static object - they are constantly changing and accommodating external forces like what we eat and drink, our anxiety and stress levels, the ambient temperature, medications etc etc. A well-kept log of your readings taken regularly, at similar times every day, can provide us doctors with a much clearer picture of your blood pressure. It also eliminates those falsely high BP readings.

Who should home monitor?

• Patients starting meds for high blood pressure to determine its effectiveness
• Patients that need closer monitoring than occasional office visits provide, especially individuals with coronary heart disease, diabetes and/or kidney disease
• Pregnant women since preeclampsia or pregnancy-induced hypertension can develop rapidly
• People who have some high readings at the doctor's office, to rule out white-coat hypertension and confirm true HBP
• Elderly patients, because the white-coat effect increases progressively with age
• People suspected of having masked hypertension

Who should NOT home monitor?

People with atrial fibrillation or other arrhythmias may not be good candidates for home monitoring. Why? Oscillometric-method monitoring devices recommended for use at home may not be able to give accurate measurements for people with these conditions. If your doctor recommends home monitoring, have your monitor's readings compared to readings taken by your office using the manual approach.


What type of monitor should I get and where?

The American Heart Association recommends an automatic, cuff-style, bicep (upper-arm) monitor. Wrist and finger monitors are not recommended because they yield less reliable readings.

A quick look on Amazon.com yielded a variety of automatic cuffs ranging from about $30 - $60.

 Search Amazon.com for bp monitor automatic

Your local pharmacy would also be a good resource but you should not have to pay more than $60 for a reliable cuff. Make sure it is automatic and not aneroid. If you have extra large arms, make sure the cuff fits before you purchase it.


What is the best way to measure my BP?

• Measure around your upper arm and choose a monitor that comes with the correct size cuff.
• Be still.
• Don't smoke, drink caffeinated beverages or exercise within the 30 minutes before measuring your blood pressure.
• Sit correctly.
• Sit with your back straight and supported (on a dining chair, for example, rather than a sofa). Your feet should be flat on the floor; don't cross your legs. Your arm should be supported on a flat surface (such as a table) with the upper arm at heart level. Make sure the middle of the cuff is placed directly over your brachial artery. Check your monitor's instructions for an illustration or have your healthcare provider show you how.
• Measure at the same time daily.
• It's important to take the readings at the same time each day, such as morning and evening, or as your healthcare professional recommends.
• Accurately record all your results.
• Record all of your readings, including the date and time taken. Share your blood pressure records with your healthcare team. Some monitors have built-in memory to store your readings; if yours does, take it with you to your appointments. Some monitors may also allow you to upload your readings to a secure Web site after you register your profile.
• Take advantage of the American Heart Association's BP tracking tools. Heart360 allows you to track your blood pressure and the steps you're taking to manage it online. You can print your readings to take or fax to your doctor.
• Understand the readings. Optimal blood pressure is less than 120/80 mm Hg (systolic pressure is 120 AND diastolic pressure is less than 80). Read Understanding Blood Pressure Readings to learn more about what the numbers mean. Consult your healthcare professional if you get several high readings.
• A single high reading of blood pressure is not an immediate cause for alarm. However, if you get a high reading, take your blood pressure several more times and consult your healthcare professional to make sure you (or your monitor) don't have a problem. When blood pressure reaches a systolic (top number) of 180 or higher OR diastolic (bottom number) of 110 or higher, emergency medical treatment is required for hypertensive crisis.

OK! You got all that? If not, it is always here on our blog for your reference. Beyond all that is said above it is also critical to keep your doctors involved and aware.

Stay healthy!

High Cholsterol Surprises

Not all of the high cholesterol foods are as obvious as milk, ice cream and egg yolks. Staying heart healthy is all about being aware of the not-so-obvious things that put you at elevated risk for coronary artery disease. So here's a few more clandestine cholesterol-containing food items:

1. Lobster - If you listen to most of my patients, they will tell you that anything that tastes good, is probably not good for you. And sure enough, this most prized crustacean packs a walloping 61 mg of cholesterol in every 3 oz bite! Add the melted butter and you might as well schedule your stress test for the following week. If you're going to splurge, avoid the butter (or most any "dipping" sauce for that matter), steam that sucker and watch your portions! By the way, processed shrimp, crab cakes and anything fried also have super high levels of cholesterol as well.

2. Chicken - But you were told it's so healthy, right? Well, it all depends on how it's prepared. With the skin on, a drumstick has more cholesterol than a cup of ice cream or a burger. Also, the dark meat, which tends to contain more fat, is higher on cholesterol. When the chicken is breaded, egg-dipped, fried, sauteed in butter/oil it becomes no more healthy than any of the other offenders above. Bake or broil it, stick to the white, skinless meat and surround it with vegetables - not batter.

3. Liver - While most of the younger readers will cringe at the thought of eating liver there are still many out there who gladly smother it in onions, spread it on a cracker or choose it in a fine dining establishment where it gains the much prettier title of foie gras. But no matter what name it is give, this organ meat is like the motherload of cholesterol, amassing more than a single day's daily allowance in one 3 oz chunk. Yikes! If you need further discouragement, just picture it when it's raw and that should do the trick.

4. Mashed potatoes - Surprise! They're not really much healthier than fries. The majority of recipes for this classic American side dish involve whole milk, lots of butter, and sour cream - the perfect storm. Throw some liver on top and you might break some kind of record.

5. Movie theatre popcorn - There seems to be a popular myth that popcorn is a healthy snack. This is very untrue unless you're popping those kernels in a pan by yourself, without oil. WebMD reports that Regal Cinema's medium-sized popcorn has a whopping 60 grams of saturated fat and 1,200 calories. Not healthy! Definitely do not add any of the liquid coronary-clogging butter and go for the small - we want you to have some enjoyment!

Stay tuned for the next installment where we discuss foods that may actually improve your cholesterol profile.

The Cholsterol Offenders - The No Brainers

Many of you out there already take a medicine for high cholesterol or have been instructed to eat a healthier diet in order to avoid medication in the future, aka the "borderliners". Both the frankly dyslipidemic and the borderliners will see heart docs like us in the office and tell us 'my doctor told me to avoid foods high in cholesterol - but I'm not sure what those foods are.' So, for your reading pleasure, we present The Cholesterol Offenders:

THE NO-BRAINERS

1. Eggs - The yolk's on you if you didn't know this one. (Sorry, but I couldn't resist). Turns out that an egg yolk has an offensive 1234 mg per 100 gram serving of cholesterol, or 411% of the recommneded daily allowance (RDA) of cholesterol. That means that just one little yolk will give you 70% of the day's RDA and if you're lucky enough to get the double yolk - well, you can do the math. By the way, the rest of the egg only provides an addition 1% of the RDA so no need to avoid the egg whites.

2. Butter - On bread, in a pan, or used in cookies, cakes and muffins, butter is a huge offender. 1 stick has 243 mg and 1 TBS contains 30 mg, 10% of the RDA. Switch to something healthier like olive oil.

3. Fast food - There's no denying that some fast food, at the right time tastes good; and its cheap. But it is flat out unhealthy. Everdayhealth.com reports that a a McDonald's Big Mac has 85 mg of cholesterol, 33 grams of fat and 600 calories. Throw in a large fries and you add 525 more calories, 24 grams of fat and 21 mg of cholesterol for a grand total of 1125 calories, 57 grams of fat and 106 mg of cholesterol. Can you feel your arteries clogging? But the true cholesterol killers in the fast food family are the breakfast sandwiches. The classic Egg McMuffin which most adult males can take down in 5 bites has a whopping.... wait for it.....235 mg of cholesterol in one small sandwich. That is almost the entire day's tolerated cholesterol before 9 am. Ouch, my chest. Other chains are just as bad, and some are even worse so don't think that it's better at BK or Wendy's no matter what the ad campaigns tell you. Check out

4. Cheese - When you say Wisconsin, I think of 2 things: cheese and offensive linemen. Both come in large quantities and high quality in The Badger State and there's a reason for it. While cheese can be a great source of protein, it is also a hefty cholesterol load. Cheddar, gouda and of course, cream cheese, and any whole milk-based cheese are ones to avoid if possible. And by the way, this also includes Mac and Cheese, which combines whole milk and butter with cheese to make a cholesterol nightmare.

5. Ice Cream - We are taking down all the good Ol' American comfort foods. While it may seem refreshing and delicious on a hot day, it's a cold-blooded coronary assasin. One cup of the smooth dessert has more fat than a hamburger and more cholesterol than 10 glazed doughnuts. Egads, pass on the ice cream and go with yogurt or fruit.

Stay tuned for our next post when we point out 5 high cholesterol foods that will surprise you...

Quitting Smoking Great for Your Heart - And Wallet

According to a recent study by the University of Wisconsin's Center for Tobacco Research and Intervention, the cost of smoking cessation pales in comparison to the annual impact of cigarettes on your bank account. Oh yeah, and did we mention that smoking is horrible for you and causes lung cancer, coronary artery disease, impotence and peripheral artery disease?

The average cost of a pack of smokes is $5.51, which amounts to about $2,000 per year if you're anywhere close to a pack per day. If you're  living in one of the many places that has taxed cigarettes, then you are paying almost double that. A brief search on Expedia.com shows you that this is more than enough to take your spouse/friend/co-quitter with you on a Caribbean cruise on any major cruiseline. Hmmm, smell like smoke, increase my chance of multiple diseases or take a Caribbean cruise and improve my overall health substantially? It's a tough one.

Free Quitting Resources:

• Call the toll-free number (800) QUIT-NOW (1-800-784-8669)
• Smokefree.gov, a Department of Health and Human Services website.

More resources and the full body of the news article can be found by clicking here.