Northern California Cardiologists and Emergency Medicine Expert Provide an Update On STEMI (Severe Heart Attacks) and Sepsis Protocols

New developments to aid in the diagnosis and timely treatment of severe heart attacks and related infectious conditions were the topics discussed recently at the Regional STEMI Program and Sepsis meeting at the John Ash Restaurant at the Vintner’s Inn Event Center.

Drs. Patrick Coleman, Thomas Dunlap and Tucker Bierbaum

Drs. Patrick Coleman, Thomas Dunlap and Tucker Bierbaum

Dr. Thomas Dunlap and Dr. Patrick Coleman, cardiologist with Northern California Medical Associates, Inc. and Dr. Tucker Bierbaum with Emergency Medicine at St., Joseph Health System’s Santa Rosa Memorial Hospital, co-hosted the biannual dinner meeting. They observed that both STEMI and Sepsis conditions present in similar ways and require time-critical intervention to avoid large area heart damage and progressive infections that can result in mortality.

According to Drs. Coleman and Dunlap, the medical community has come a long way in implementing timely procedures to treat patients with STEMI. “Cardiologists in the late 1990’s and early 2000’s began treating heart attack patients with intravenous stents, catheterization and balloon angioplasty – as well as drug-covered stents and balloons — for faster, more effective intervention — as opposed to just prescribing drugs to open clogged arteries which can take longer to do their job. The heart continues to suffer damage as long as the arterial occlusion remains. This new treatment strategy yields remarkable benefits in terms of less heart damage and improved patient prognoses.”

Dr. Dunlap said, “The STEMI Program has instilled a pervasive sense of urgency in people involved in administering the heart attack response protocol, and our efforts are paying off. The new STEMI treatment approach has been so successful that it’s not uncommon for patients that get picked up by EMS personnel at referral hospitals in Petaluma or Healdsburg to have their lifesaving device implanted within the next 90 minutes. There is still plenty of work to be done to increase STEMI response efficiency even further.

Dr. Coleman addressed the necessity of adhearing a standardized response protocol. “The urgency of any heart attack situation requires that all caregivers involved, including the paramedics, firemen, ED triage nurses, ED physicians, and cardiologists, perform precise tasks with efficient command and expertise.”

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All of the presenters at the meeting emphasized the vital importance of education and teamwork in an era marked by new techniques, technology and procedures. “It’s our job as cardiologists to educate everyone involved about their essential roles in saving heart attack patients’ lives,” Dr. Coleman added. “We know what needs to happen for STEMI patients to be treated effectively. Only through unified countywide planning and optimal utilization of local emergency facilities can we give patients their best chance for survival.”

A key barrier to the proper diagnosis of STEMI (ST-segment elevation myocardial infarction, or a severe heart attack) is that while EMS personnel and paramedics in the field can take EKG readings on site, or as they transfer the patient in an ambulance, they do not have the expertise or authority to read the tape and determine whether a STEMI incident has occurred. Only a cardiologist seeing the tape can make this assessment.

When a suspected heart attack victim is received by EMS personnel, they immediately call ahead to the nearest regional center emergency department (ED) to alert the cardiologist on duty so cath lab team members can be assembled in advance to save time.

“Without proper diagnosis, paramedics cannot know with certainty how to proceed and implement the correct treatment protocol unless a cardiologist miles away at a regional emergency department catheterization lab reviews the EKG tape,” Dr. Coleman continued. “So the quest has been to find a way to transmit EKGs to the cardiologist for precise interpretation while the patient is still in transit.”

Most facsimile machines are only capable of transmitting relatively low-resolution images. However, today’s cell phones have high-resolution cameras that can produce detailed images fine enough for an accurate STEMI diagnosis. Now a picture can be taken of the EKG tape in the field and transmitted to a physician in seconds, cutting the time interval for obtaining a diagnosis and treatment authorization during the journey from the field to the hospital, while also enabling the EMS to start appropriate medication therapy enroute.

The ability to transmit the photo image depends upon physical access to the nearest cellular signal relay tower. But even in remote areas beyond cell reception a moving vehicle often will enter an active cell zone within a few miles and be in a position to relay the picture before arriving at a hospital. HIPPA patient security and privacy considerations are avoided by asking the patient for permission to send the photo via a cell call prior to transmitting it.

In another innovative example, a Cotati-based medical transport company (ProTransport-1) has introduced ambulance technology that uses Google Glass camera-equipped spectacles worn by emergency technicians that transmit what they’re seeing to awaiting hospital staff.

The Google Glass system in the ambulances will allow EMTs, paramedics and nurses to transmit live video to receiving health care facilities during transports. In addition to mobile, visual evaluations, this versatile technology can improve the efficiency of patient care, documentation, navigation, dispatch communication and many more operational processes in the health care, ambulance and EMS industries.

“We’ve learned how to do many things well and still want to find ways to do them better, by focusing on a single process with ramifications based on how what you do will save lives, time and reduce costs,” Dr. Dunlap explained. “New communications technology is helping us expedite patient care before they arrive at the ED.”

Dr. Dunlap said the incidence of STEMI has decreased over the years, while the incidence of non-STEMI MI’s has gone up (1.6 cases per 1,000). Delays in treatment for STEMI come with a human cost per hour. Studies show that up to 40 lives can be saved for each hour medical personnel do better at identifying causes and administering proper treatment. For example, in door-to-balloon angioplasty therapy to unblock arteries, any time saved below 90 minutes makes a big difference in the 30-day mortality rate.

He said referral hospitals are good at processing patients quickly for transfer, and all regional medical centers have a reputation for rapid assessment of a patient’s condition, reducing the time required to implement treatment in receiving hospitals.
In an ideal scenario, ambulances equipped with EKGs would transmit the tape to the ED at the receiving hospital while adhering to standard protocols for drug stabilization and transfer from referral hospitals. The majority of the work will be done at the STEMI receiving hospital based on a single call from the field. This enables a classification of the case by level of evidence and severity.

The treatment ladder protocol for regional programs has been developed in consultation with Dr. David Lee at Stanford University with the goal of identifying a patient with ST elevation MI and directing the transport team to a STEMI-designated receiving hospital with a cath lab within 1.5 hours or less.

Dr Tucker Bierbaum

Dr. Tucker Bierbaum (R) of St., Joseph Health System’s Santa Rosa Memorial Hospital

Also presenting was Dr. Tucker Bierbaum, with St., Joseph Health System’s Santa Rosa Memorial Hospital. Dr. Tucker contends that Sepsis is an issue with increase prevalence and diagnosis. From 2012-13 there was an 11% increase in Sepsis in the region affecting 122 per 10,000 of population with those in the 65+ age group most severely affected, as well as those with weakened immune systems. During this time frame, Sepsis accounted for 40% of intensive care unit (ICU) costs and involved longer hospital stays. Those with Sepsis have a high recidivism rate. When not treated in time, the condition can lead to permanent renal disease.

Sepsis is one of four pathologically similar and progressive conditions beginning with SIRS (systemic inflammatory response syndrome), Sepsis (a potentially life threatening complication of infection due to the presence of bacteria or other infectious organisms in the blood stream that can spread throughout the body), Severe Sepsis (Sepsis with organ failure) and Septic Shock (Sepsis with multiple organ dysfunction or death).

For STEMI cases, two sets of protocols were discussed, including what to do during the first three-hours utilizing the initial bundle of treatment procedures, and what to do during the next three-hour period, as well as what medications have proven to be most effective in addressing this condition.

Regular meetings such as this and the quality of information provided are the keys to continuous improvement through education, as representatives from referral and regional hospitals come together to learn about new developments that can make the health care system better and improve patient outcomes.

NCMA Cardiologist Jaime Molden Explains Latest in Catheter Ablation Treatment for Atrial Fibrillation

 Jaime Molden, MD, FACC, FHRS Electrophysiologist


Jaime Molden, MD, FACC, FHRS
Electrophysiologist

Northern California Medical Associates (NCMA) Cardiology offers expert atrial fibrillation care from leading specialists in the North Bay region. Cardiac Electrophysiologist Jaime Molden explains the current guidelines for treating atrial fibrillation with catheter ablation—an invasive, nonsurgical procedure that may reduce patient reliance on toxic medications.

Atrial fibrillation (Afib) is a common, potentially life-threatening heart condition in which the upper heart chambers beat out of sync with the lower chambers, causing an irregular heartbeat. Although the arrhythmia causes only a small increase to one’s risk of early death, the condition can evolve when left untreated over time and become very serious. In addition to life-changing symptoms of fatigue, palpitations, shortness of breath, inability to exercise, chest pain, and syncope, patients with Afib live with increased risk for an array of serious life-threatening health problems including stroke, cardiomyopathy, and heart failure.

Cardiologists have been helping patients manage their Afib for decades primarily with anti-arrhythmic drugs (also known as AADs or “rhythm drugs”). While these drugs are proven effective, the degree of efficacy varies from patient to patient, and side effects from taking these medications over extended periods of time can cause serious complications. Catheter ablation for Afib first became a viable treatment option in the early 1990s, and researchers and cardiologists have studied its efficacy ever since, fine-tuning the procedure throughout the process. Today, catheter ablation is gaining traction in the treatment of Afib as it has shown to help certain patient groups return to healthy heart rhythms while reducing their reliance on medications, which can have significant side effects.

NCMA Cardiologist Jaime Molden, MD, studied cardiac electrophysiology during his fellowship at Cedars Sinai Medical Center in Los Angeles. Dr. Molden regularly treats patients with Afib and he is a leading specialist in the area of catheter ablation techniques.

Dr. Molden explains, “Treating Afib remains a challenge to cardiologists today. There are three types—paroxysmal, persistent, and permanent—and treatment varies depending on which type the patient has. Paroxysmal is generally described as lasting less than 48 hours at a time. Persistent Afib lasts more than a week or requires an intervention to terminate it. Permanent Afib lasts longer than a year. Paroxysmal Afib patients have better treatment prognoses than persistent and permanent patients, but both paroxysmal and persistent Afib can become more frequent over time if untreated or treated ineffectively. Since many treatments are available but none that will work the same for every patient, treating Afib demands cardiologists’ full attention to detail in each individual case.

Treatment of Afib is always individualized to the patient. Many patients want to get off of their anti-arrhythmic medications altogether, and others want to simply minimize symptoms. When symptoms persist, more catheter ablation procedures can often get patients to where they want to be, with the type of Afib playing a significant role in the efficacy of the treatment. Patients with paroxysmal Afib can achieve excellent results with a single ablation procedure.

In the procedure, we use several different diagnostic catheters and an ablation catheter to map out and treat the areas of the heart that are causing the abnormal rhythm. In the vast majority of patients, arrhythmia is triggered by pulmonary veins firing electrical signals in an irregular, chaotic pattern. With catheter ablation, lesions (‘burns’) are made around the opening of each pulmonary vein until there is no electrical conduction into the vein. What we are essentially doing is cutting off ‘communication’ between the misfiring vein (or veins) and the heart by modifying the tissue in a precise area. We can then test the results to ensure that there is no conduction between the heart and the misfiring vein. After catheter ablation, a patient’s pulmonary veins will still fire an electric signal that would normally cause arrhythmia, but the signal cannot pass through the ablated tissue, and sinus rhythm (normal rhythm) is maintained.

Catheter ablation for atrial fibrillation is becoming more widely used within the medical community for several reasons. It likely has a more favorable success rate than anti-arrhythmic drugs. Analysis of landmark Afib trials like AFFIRM, RACE and RACE II suggests that rhythm control with drugs and cardioversion benefit the patient by maintaining sinus rhythm, but the toxicities and adverse effects associated with AADs negate the positive effects. The subset of patients who responded well to the treatment, meaning that their normal rhythm was maintained with little adverse reactions to the drugs, had lower morbidity rates than the overall population of patients in the study. This suggested that non-pharmacologic therapies might allow us to achieve the larger benefits of maintaining sinus rhythm.

While studies into the efficacy of catheter ablation are ongoing, results from recent research demonstrate that approximately 60-70% of patients with paroxysmal Afib can enjoy freedom from arrhythmia after a single procedure. With two or more procedures, the efficacy increases further. The research also indicates a higher success rate for paroxysmal patients when compared to rates for persistent or permanent Afib patients. Patients with paroxysmal Afib, accordingly, are better candidates for the procedure than those living with the persistent types.

The risks associated with catheter ablation are serious, but the propensity for major complication is approximately 2% with the overall complication rate in the range of 5%. Compare that number with the propensity for complications associated with anti-arrhythmic drug treatment, and the risks of catheter ablation look even better. While rhythm drug treatment has a lower rate of life threatening side effects than ablation, almost a third of patients on these medications eventually experience an adverse event caused by their treatment, like severe heart rate slowing or the precipitation of other abnormal heart rhythms. Over 10% of patients either find the treatment too intolerable to continue or altogether ineffective.

This leads to the important question—‘When is the use of rhythm drugs warranted?’ New official Afib treatment guidelines in the US now include a treatment route for Afib that removes AADs from the process altogether, allowing patients to opt for ablation before they’ve tried AAD therapy. This is exciting progress, as the new guidelines demonstrate a trend towards replacing a standard treatment with a potentially better one. With that said, we do not have a curative treatment for Afib in 2014. The treatment for this disease will continue to be a combined approach utilizing the existing medicines in as safe a way as possible while applying catheter ablation techniques to the patients who prove to be good candidates.

A trial run with medications is still generally seen as the first option for Afib patients. Also, patients with persistent or permanent Afib may not be eligible for the ablation procedure depending on various cardiac and overall health factors. Catheter ablation for treating Afib has settled in as a viable treatment for patients that meet the right criteria, both without and in conjunction with medications. For some patients, catheter ablation may offer the best outcomes.”

Click here to view Dr. Molden’s complete presentation on Afib catheter ablation from NCMA’s annual symposium.

NCMA offers patients excellent quality and convenience in its comprehensive cardiac and vascular testing services. All procedures are performed by highly skilled and trained registered sonographers, registered nuclear technologists, and/or registered nurses and medical assistants, under the support of our physicians. NCMA’s nuclear and echocardiology laboratories are accredited by the Intersocietal Accreditation Commission. To learn more about NCMA Cardiology or Dr. Molden, please visit www.ncmahealth.com, or call (707) 573-6166 to schedule an appointment.

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NCMA Cardiology Launches “Be Heart Smart” Campaign During National Heart Month

February is American Heart Month, and Northern California Medical Associates (NCMA) Cardiology is kicking off its “Be Heart Smart” campaign to do its part to spread heart health awareness. Since 1975, NCMA Cardiology has focused on educational outreach in addition to providing a comprehensive range of cardiac services from highly trained, elite physicians. With the “Be Heart Smart” campaign, NCMA Cardiology aims to educate the public about various aspects of heart health in order to empower people to make the right choices and to live a heart healthy life.

Be Heart Smart fb masthead

Heart disease has been the number-one killer of Americans for the past 80 years. In 2015, it isn’t news to most people that heart disease is the leading cause of premature death in the United States. It also isn’t news to most people that heart disease is preventable. The shocking news is that even though people know the risks of heart disease and that it is preventable, the incidence of heart disease and related deaths continues to grow. According to the American Heart Association, one in seven deaths is related to coronary heart disease, and one in nine is caused by heart failure. In light of the growing problem, February has been deemed “Heart Month” in America. NCMA Cardiology has launched its “Be Heart Smart” social media campaign this month as a means to help people realize the power of preventative healthy living to reverse the trend of rising heart disease.

While there are some risk factors you can’t control such as age, gender, heredity, and race, people can significantly mitigate their risk for heart disease by making healthy lifestyle choices. With its campaign, NCMA Cardiology hopes to reach as many people as possible and to cause them to stop and think about their hearts when making health-related choices. NCMA cardiologists have identified seven interrelated goals that will help people reduce their risk for heart disease. In essence, the “Be Heart Smart” campaign is about (1) managing diet and weight, (2) exercising regularly, (3) quitting smoking, (4) reducing stress, (5) keeping blood pressure in the healthy range, (6) managing cholesterol levels, and (7) controlling blood sugar.

First and foremost, managing diet and weight is the most important step towards minimizing one’s risk of heart disease. NCMA Cardiology strives to redefine the meaning of ‘diet’ in popular culture. One’s diet encompasses everything he or she ingests over a lifetime. Alternatively, when one ‘goes on a diet,’ this most likely means the dieter is resisting the foods that he or she prefers to eat for a set period of time for the sake of losing weight. This type of dieting is not an effective way to sustain weight loss, as once the diet ends, the person rewards themselves with the unhealthy foods they resisted while dieting. To truly have a healthy diet, NCMA cardiologists recommend eating smaller portions at meals, and snacking on vegetables and fiber-rich whole grains during the day. Allow yourself to indulge in high-fat, and high-sugar foods, but don’t overdo it. Your diet does not have an end-date.

While obesity poses one of the most serious threats to heart health, you don’t have to be obese to have an increased risk of heart disease due to a poor diet. Everyone’s body processes food differently. Although it is unlikely, some people can appear slim and fit while sustaining themselves on potato chips and soda pop. This does not change the fact that these people are increasing their risk for heart disease through their diets. What foods are really the best for your heart? Recent studies have shown that the “Mediterranean diet” can reduce the risk heart disease by about 20% in both men and women.

“Just taking a walk in the morning or the evening will put you on your way to better heart health.”

After maintaining a healthy diet, exercising regularly is the next most important step towards reducing hearth health. Not only will living a sedentary lifestyle reduce muscle strength and endurance, it will also contribute to metabolic problems such as high blood sugar and cholesterol. Much scientific research has gone into how much exercise is enough, and today’s leading experts recommend getting at least 60 minutes of continuous, moderate aerobic exercise each day of the week. NCMA cardiologists recognize that this recommendation is more than what many Americans are willing to do or have time for, so they level with patients and tell them the raw facts—true up until the extreme, the more cardiovascular exercise people get everyday, the more they reduce their risk for heart disease. While 60 minutes a day brings about excellent health benefits, even just 20 to 30 minutes of continuous, moderate aerobic exercise five days a week has been shown to reduce the risk for heart disease by 30-50%. Just taking a walk in the morning or the evening will put you on your way to better heart health.

It shouldn’t come as a surprise to anyone that smoking dramatically increases your risk of cardiovascular heart disease. Like it says on every cigarette box today, smoking causes heart disease. Smoking accelerates the progression of heart disease in people predisposed to having it, and drastically increases the chances of it developing in people who would otherwise be at a very low risk. In conjunction with the Northern California Center of Well-Being, NCMA offers smoking cessation classes. Even if you aren’t ready to quit, it is important to talk to your NCMA physician about your smoking habit so that he or she may provide you with all of the resources, clinics and classes offered through NCMA.

When it comes to reducing stress, it is important to clarify what kind of stress is most necessary to reduce for the sake of improving heart health. Reducing physical stress such as exercise, for example, should not be thought of as an effective means to reduce one’s risk of heart disease. Emotional stress, such as work-related, relationship, and financial stresses, has long been suspected and recently confirmed to increase one’s risk for heart disease. These types of stresses, however unpleasant or dangerous, cannot always be avoided. Reducing stress, therefore, is ultimately about finding ways to relax when confronted with stressful situations. No two people will ever react to the same type of stress the same way, so it is also important for individuals to determine the stresses that affect them most. Avoid them when you can, and find relief through deep breaths and communal support when you can’t. Include your doctor in conversations about your stress levels for further feedback and advice.

High blood pressure, high cholesterol, and off-balance, volatile blood sugar levels are all relatively common in our society and can significantly increase one’s risk of developing heart disease. While the best way to mitigate these risks is through exercise, healthy eating, and not smoking cigarettes, treatment may require management with drug therapy and careful monitoring by your physician. Other contributing factors other than lifestyle choices such as genetics and metabolic disorders are often unavoidable and may warrant even closer care with your doctor.

Improving your heart health and reducing your risk for heart disease doesn’t have to be overwhelming. Simply making an effort to be conscious of heart health in your day-to-day living can go a long way. To start, NCMA Cardiology encourages everyone to pick two or three goals on the “Be Heart Smart” list to go after. In addition, keeping regular appointments with your cardiologist before any serious heart issues arise is the best way to stay on top of your heart health.

NCMA Cardiology is comprised of 14 cardiologists, two cardiothoracic and vascular surgeons, and one electrophysiologist—all board-certified in their fields. Since 1975, the group has focused on sub specialization within cardiovascular health to provide services by the most highly trained and experienced physicians and staff. In accordance with its practice of providing comprehensive cardiovascular health care, NCMA offers HeartWorks, pacemaker and defibrillator clinics, anti-coagulation clinics, congestive heart failure clinics, pulmonary hypertension clinics, lipid clinics, and an adult congenital heart clinic in addition to general check-ups with cardiologists. NCMA’s HeartWorks Cardiac Rehabilitation Center provides each patient with a personal diet and exercise plan supervised by a team of physicians, nurses, and cardiac exercise specialists.

Be Heart Smart IconNCMA Cardiology provides cardiac care in three counties, with 11 offices, located in Santa Rosa, Petaluma, Sonoma, Healdsburg, Fort Bragg, Mendocino, Gualala, Ukiah, and Lakeport. Visit our website at www.ncmahealth.com for more information on NCMA health services and contacting NCMA offices. Please call (707) 573-6166 to schedule an appointment with NCMA Cardiology, and visit NCMA’s Facebook page to follow the “Be Heart Smart” campaign.

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Northern California Medical Associates receives IAC Accreditation in Nuclear Cardiology

IACTwo Northern California Medical Associates (NCMA) locations, Santa Rosa and Ukiah, received accreditation from The Intersocietal Accreditation Committee in the practice of Nuclear Cardiology. This three-year accreditation is awarded to those facilities that provide the highest standards in patient care.

NCMA Nuclear Medicine has passed the rigorous application and needed for accreditation as well as compiling with national standards. Accreditation ensures patients that the facility has been carefully critiqued and all aspects of operations in the field of Nuclear Cardiology are up to medical standards.

With cardiovascular disease the No. 1 cause of death in the United States, early detection of life threatening heart disorders and other diseases is possible with the use of nuclear cardiology in hospitals, outpatient centers and physician’s offices. NCMA has met the requirements for nuclear cardiology testing as well as the standards demanded for other contributing factors including the skill of technologists preforming examinations, the equipment used and the background and knowledge of practicing physicians.

The Intersocietal Accreditation Committee is a widely respected organization within the medical community with support from national medical societies that include industry leaders of physicians, technologists and medical physicists. The IAC continues its twenty-year accreditation divisions by developing standards and methods for the overall evaluation of the quality of care delivered. The IAC also provides peer review processes for multiple imaging modalities within the medical community.

NCMA has led the way in exceptional patient care since 1975.  It holds the only establish cardiac rehabilitation, lipid treatment, congestive heart failure and adult fitness program north of the Golden Gate. With highly respected primary care physicians and specialists in Sonoma, Lake and Mendocino Counties NCMA is the premier provider of cardiovascular surgery state-wide and is committed to the improvement and health of its community and patients and will continue to establish and hold the highest standards for patient care.