Decline in heart disease called 'public health miracle'

Dr. Aaron Kugelmass, an interventional cardiologist shown here talking about an angioplasty and stent procedure, is vice president of Baystate Health and cardiology division chief.(Anne-Gerard Flynn photo)

In 2016, heart disease took some 633,842 lives in the United States, followed by 595,930 deaths from cancer and 155,041 from chronic lower respiratory diseases, according to government statistics.

"Heart disease and stroke remain the leading cause of death in the country, but if you look at it adjusted for population, it just keeps coming down and it is one of the public health miracles of the last century," said Dr. Aaron D. Kugelmass, vice president of Baystate Health and medical director of its heart and vascular program.

According to the American Heart Association, age-adjusted death rates for heart disease fell from 520.4 deaths per 100,000 Americans in 1969 to 169.1 in 2013. Stroke deaths dropped from 156.8 per 100,000 Americans to 36.

Death rates are adjusted for age and calculated as the number of people who die for every 100,000 people in the U.S. population.

This trend has continued as the death rate for heart disease in 2016 declined to 165.5 per 100,000. In Massachusetts, heart disease is actually second to cancer as the top cause of death. In 2016, the state had 11,921 deaths attributed to heart disease. Its death rate for this disease was 134.8 per 100,000.

Kugelmass is chief of Baystate's division of cardiology and helped develop its Davis Family Heart & Vascular Center that opened in 2012.

A graduate of Harvard Medical School who did his residency in medicine at the University of California in San Francisco, he did a four-year fellowship in cardiology at what is now Beth Israel Deaconess Medical Center.

He terms advances in the treatment of heart disease as "multi-factorial." These, he said, include better medications, education of both patients and physicians and less invasive procedures.

These include coronary angioplasty. This procedures involves a wire that is inserted into an artery in the groin area. A catheter is slid over this guide wire and up into the blocked coronary artery. The guide wire is removed and a wire with a balloon inserted into the catheter. The balloon will be temporarily inflated against the blockage before it and the catheter are removed.

Often a stent, a small mesh tube, is wrapped around a second balloon and when this balloon temporarily inflates, the stent expands against the widened artery wall and is designed to remain there.

"We do almost everything short of heart transplants at Davis," Kugelmass said.

"We are the busiest angioplasty or stent center in the state based on prior numbers. We are one of the busiest heart attack centers in the country. We are one of the busier cardiac surgery centers in the state and that includes Boston. We pretty much do a lot of everything."

He noted that a "variety of different clinical and other factors" play a role in the decision of whether a patient gets open heart bypass surgery for a blocked coronary artery or is a better candidate for coronary angioplasty.

"There might be a blockage right there, a build up of cholesterol and other things," said Kugelmass, pointing to a model of the heart as he holds a thin wire and explains coronary angioplasty.

"We take a real small wire and bring it up from the leg and bring it out from the aorta. We put it down across the blockage and then we would take this angioplasty balloon and put it across the blockage and then inflate, just like you would a balloon, but we don't use air, we use liquid. We can see the liquid on an X-ray."

Kugelmass said this "pushes the blockages out of the way."

"Ninety-eight percent of the time we would take a coronary stent, a little metal scaffold that is crimped on a balloon, and we would snake it pass where the blockage was and where we did the balloon and we would expand the artery by again inflating the balloon and that balloon deflates and that stent stays in place to open the vessel and the balloon comes out, the wire comes out and over time the body cells line the stent and it becomes incorporated into the wall of the vessel."

A few months after the Davis center opened, Baystate interventional cardiologists performed the first Transcatheter Aortic Valve Replacement in this part of the commonwealth.

The procedure is similar to angioplasty and has typically been done on patients not considered good candidates for open heart surgery. It involves replacing a failing aortic value through the insertion of a catheter, often into the groin artery, that threads the replacement value into the heart.

The day he was interviewed for this article, the same cardiologists were doing the center's first repair of a leaking mitral valve through the insertion of a catheter into an artery in the groin area. This is designed to help close the leak with a threaded clip in patients not considered good candidates for surgery.

"This procedure has been out for a few years. We are not the earliest adopter, but we are adopting it and it was not being done here before the Davis center opened," Kugelmass said.

In recent months, the center has also been placing ventricular assist devices.

"This is a surgical procedure whereby we plant a centrifugal pump which assists the heart itself in pumping blood to the body in people with very advanced congestive heart failure that results in their heart being too weak to pump blood to the body," Kugelmass said.

"They are used for patients who can't get a heart transplant but they are also used for patients whom you could bridge for heart transplant."

He cited this technology as one that "keeps evolving and the pumps keep getting smaller and more reliable."

"Newer technologies including bypass surgery and angioplasty and the application of angioplasty to acute heart attacks has markedly dropped the mortality from acute heart attacks," said Kugelmass, listing factors that have contributed to a drop in heart disease.

"Very effective and increasingly effective drugs that either manage heart disease or help prevent the disease or stabilize the disease - most noteworthy the statin drugs - but also the application of the drug asprin to heart and stroke patients. Better blood pressure control - all those things contribute to the reasons why heart disease has gone down."

He added, "The incidence of tobacco use has dropped dramatically in this country and that is another reason."

"All the things that we did right still contribute to the fact that it is the major killer and that has to do with lack of adherence to medications, lack of adherence to blood pressure management, smoking that does continue to some degree," Kugelmass said.

"It is a continuous process of improvement and not one that is black and white."

Kugelmass said the Davis Center does about 675 cardiac surgeries annually, as well as about 175 TAVRs which is being studied for use in a broader range of patients and not just those who are considerate at moderate-to-high risk for open heart surgery.

He said the center also does about 80 Endovascular Aneurysm Repairs, an approach similar to angioplasty in treating aortic aneurysms, as well as about 1,400 angioplasties annually.

In addition, some 7,000 echocardiograms are done at Baystate cardiovascular surgery sites in Springfield, Northampton and Franklin, which also handle some 42,000 ambulatory visits.

It is estimated that 790,000 adults in this country annually experience a heart attack.

"The patients who are having heart attacks are older and the types of heart attacks they are having are actually changing," said Kugelmass, referencing severe heart attacks involving a complete blockage of a heart artery and showing a certain heart pattern on an EKG.

"The ST elevation myocardial infarction is decreasing in numbers, and that is probably attributable to the reduction in smoking and better control of the statins."

Still, Kugelmass said he is "concerned that weight, the lack of activity, the increasing prevalence of diabetes puts at people at risk" for cardiovascular disease.

One recent study from the Cleveland Clinic looked at men who had severe heart attacks over a nearly 20-year time frame. It divided the men into five-year time spans and found those in the more most recent span were younger and had higher percentages of risk factors considered preventable, such as smoking, than those in the earliest time span.

Kugelmass said it should also be noted that women, too, are at risk, for cardiovascular disease something that has become better known in recent years as the disease is studied in women.

"It is the No. 1 killer of women as well as men. What has changed in the last 10 or 12 years is the understanding that women do get heart disease and a lot of attention has been put forward to educate women and let them know that they, in fact, can have heart disease," Kugelmass said.

"Women tend to present later in life with heart disease probably because of hormonal issues," Kugelmass said.

He added, "The symptoms of heart disease in women are sometimes more subtle and different than they are classically in men, although they can be subtle and different than they are classically in men as well."

"Heart attack for women might not be crushing chest pain - it might be a vague ache. It might be a sense of fatigue. It might be "I don't feel right.' It might be dizziness or couldn't catch a deep breath, but, in men, too, the more you query them, it is not always crushing substernal chest pain," Kugelmass said.

"There are multiple types of heart attacks, but the classic heart attack is most classically caused by a cholesterol deposit in the artery rupturing or fissuring and a blood clot forming," Kugelmass said.

He noted there are online assessments, as well as risk estimator apps, for evaluating an individual's risk for developing cardiovascular disease.

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