Hot Topics in Cardiology

Leaders in Cardiovascular Excellence Where Patients Come First Hot Topics in Cardiology Dr. Joshua D. Cohen is a Fellow of the American College of Cardiology and the Society of Cardiovascular Angiography and Interventions. He has a total of six board certifications. Dr. Cohen is Board Certifi ed in Cardiovascular Disease, Nuclear Cardiology, Echocardiography, Vascular Medicine, Interventional Cardiology and Internal Medicine. Dr. Cohen completed his General and Interventional Cardiology Fellowship, Residency and received his Doctor of Medicine degree from the University of California, San Francisco. He received his undergraduate degree with distinction from Stanford University. He consults at the Baywood, Dobson, and South Gilbert offi ces and also preforms procedures at the Vein Center. Spider Veins: The Tip of the Iceberg Spider veins are small, thread-like veins that occur near the surface of the skin and often appear on the legs or face. They can appear as red, purplish, or blue veins and often look like tree branches or spider webs with jagged edges that grow outward. Spider veins can cover a small area and avoid notice, or they can cover a larger area and become unsightly. It is also possible that they may enlarge over time. Spider veins, or telangiectasias, are often related to (and may appear in combination with) varicose veins and can derive from the same underlying causes. They occur in the capillaries closest to the surface of the skin, which are fed by veins called reticular veins (also know as feeder veins ). Spider veins may be a sign of more serious underlying vein disease such as venous insufficiency or venous reflux and should be brought to the attention of your cardiovascular specialist at Tri-City Cardiology. Causes of Spider Veins The most common cause of spider veins is genetic predisposition. They occur more frequently in woman and during pregnancy. They also may be the result of a traumatic injury. Spider veins on the face may be related to excessive sun exposure. Prevention of Spider Veins: Not all varicose and spider veins can be prevented. But, there are some steps you can take to reduce your chances of getting new varicose and spider veins. These same things can help ease discomfort from the ones you already have. 2nd Quarter 2014 www.tricitycardiology.com Page 1

Exercise regularly to improve your leg strength, circulation, and vein strength. Focus on exercises that work your legs, such as walking or running. Control your weight to avoid placing too much pressure on your legs. Elevate your legs when resting as much as possible. Don t stand or sit for long periods of time Wear elastic support stockings and avoid tight clothing that constricts your waist, groin, or legs. Spider Vein Treatment The most common spider vein treatments are sclerotherapy. Sclerotherapy involves the injection (directly into the spider vein) of a chemical solution that will close the offending vein, causing it to disintegrate. If underlying venous disease is present, other vein treatment methods may need to be employed such as vein ablation for underlying venous reflux disease. Spider veins, once treated, may appear to recur with time, but often this is the result of new spider veins growing in nearby capillaries. If this occurs, additional spider vein treatments may be necessary. Did you know that Tri-City Cardiology has a new Vein Center with a comprehensive treatment approach to vein disease? Treatments are offered for chronic venous insufficiency, venous reflux, varicose veins, and spider veins. Please ask your physician if a referral to a vein specialist at Tri-City Cardiology is appropriate for your specific situation. -Joshua Cohen, M.D., F.A.C.C, F.S.C.A.I., R.P.V.I. New Guidelines to Treat High Blood Pressure Dr. Todd Perlstein is a recognized national authority on hypertension. He is board certifi ed in Cardiovascular Disease, and most recently served as a faculty member at Harvard Medical School. Dr. Todd Perlstein has published more than 30 articles and textbook chapters, focusing on hypertension and vascular medicine, and serves as a reviewer of 20 different peer-reviewed academic journals. He completed his education at the University of Arizona College of Medicine, and thereafter trained at Emory University and Harvard Medical School Brigham & Women s Hospital. He has presented extensively in national meetings, and has conducted advanced research in the fi elds of hypertension management and endovascular diseases under the support of the National Institute of Health, American College of Cardiology, and American Heart Association. He joined Tri-City Cardiology in 2012, and now practices along side his father, Dr. Edward Perlstein. Dr. Todd Perlstein consults at the Dobson and South Gilbert offices. Millions of Americans either have or are at risk for cardiovascular disease (e.g. heart disease, stroke, aneurysm). The treatment of hypertension (high blood pressure) is one of the best ways to prevent the development of cardiovascular disease. Hypertension is quite common, present in approximately two thirds of United States (US) adults 60 years of age and older. For these reasons, hypertension is one of the best-studied conditions in adult medicine. Despite 40 years of intensive clinical research, however, the ideal treatment of hypertension remains rather uncertain. Page 2 www.tricitycardiology.com 2nd Quarter 2014

Highlights Of Changes In New Blood Pressure Guidelines 1. For adults aged 60 years, the target blood pressure is < 150/90 mm Hg, increased from the previous target of < 140/90 mm Hg. 2. For adults with diabetes and/or kidney disease, the target blood pressure is < 140/90 mm Hg, increased from the previous target of < 130/80 mm Hg. 3. Beta-blocker medications (e.g. atenolol, metoprolol) are no longer recommended as a first-line treatment for hypertension; they are to be used only after several other medication classes have failed to adequately lower the blood pressure. 4. Blood pressure medications should be adjusted or added monthly until the target blood pressure is achieved. A new set of guidelines for the treatment of hypertension in US adults were published earlier this year (February, 2014). The intent of these guidelines is to help physicians provide the best possible treatment for their patients with hypertension. These guidelines potentially impact a large number of Tri- City Cardiology patients. The guidelines begin with a controversial recommendation that for adults aged 60 years or older, the target blood pressure (BP) to achieve is less than 150/90 mm Hg. Many of you will immediately recognize that the target had been a BP of less than 140/90 mm Hg. The reason for this change is not that it isn t better to achieve a BP less than 140/90 mm Hg in older adults, but rather that no trial has proven this. In other words, it may be better to achieve a BP less than 140/90 in older adults, we just don t know for sure. The guidelines do state that if the BP is treated to less than 140/90 mm Hg and the patient is doing well, that treatment does not need to be adjusted to get the BP to increase to above 140/90 mm Hg. There are three groups of patients for whom the BP goal remains less than 140/90 mm Hg. The first is adults aged less than 60 years. The second is adults aged 18 years or more with diabetes. The third is adults aged 18 years or more with reduced kidney function (e.g. chronic kidney disease). The previous recommendation for patients with diabetes and/or kidney disease was to target a BP less than 130/80 mm Hg. As before, the change in the recommendation was because it has not been proven that a BP target of less than 130/80 mm Hg in patients with diabetes and/or kidney disease is better than BP target of less than 140/90 mm Hg. The new guidelines also change which medications are recommended as initial treatment for patients with hypertension. Perhaps the most striking change is that the beta-blocker (e.g. atenolol, metoprolol) class of BP medication is no longer recommended as the initial treatment. For decades many physicians have chosen a beta-blocker as the first medication for patients with hypertension, but the new guidelines point out that beta-blockers do not work as well as other commonly used hypertension medications (i.e. diuretic (e.g. hydrochlorothiazide), calcium channel blockers (CCB, e.g. amlodipine), ACE inhibitors (ACEI, e.g. lisinopril) or ARB (e.g. losartan). For the majority of adults with hypertension, any diuretic, CCB, or ACEI/ARB medication is recommended as initial treatment. For African American adults, diuretic and CCB are preferred, and for adults with kidney disease, ACEI/ARB are preferred. Finally, the guidelines recommend that BP medications be added in rapid succession until target blood pressure is achieved, giving each a one-month chance to show its effect, and discontinuation of a medication that seems to have no benefit. -Todd S. Perlstein, M.D. I Have High Blood Pressure; What Should I Do? 1. Partner with your doctor to establish a treatment strategy that works for both of you. 2. Eat a healthy diet that emphasizes fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. Avoid excessive sodium intake. 3. 4. Exercise regularly. Aim for 40 minutes of moderate aerobic exercise 4 times per week. Avoid excessive alcohol intake (> 2 alcoholic beverages per day). 5. Get regular sleep, and be tested for sleep apnea if you remain sleepy during the day or if someone tells you that you appear to periodically stop breathing or choke while you are asleep. 2nd Quarter 2014 www.tricitycardiology.com Page 3

Dr. Kai Sung is an electrophysiologist at Tri-City Cardiology. He is board certified in Cardiovascular Diseases, Cardiac Electrophysiology, and Internal Medicine. Dr. Sung completed his education and training at Columbia University, Baylor College of Medicine, and Brown University. While at Brown, Dr. Sung trained under Dr. Alfred Buxton, a world renowned expert in arrhythmia medicine. Dr. Sung is a Fellow of the American College of Medicine and a Fellow of the Heart Rhythm Society. He has lectured extensively in both national and international forums, and has conducted advanced research in the fi elds of arrhythmia ablation and heart failure devices. Dr. Sung consults at the offi ces of Baywood, Dobson and South Gilbert offices. A Comparison of New Oral Anticoagulants (NOACs) and Coumadin While Coumadin has existed since the 1940s, it remains an important therapeutic option for many cardiac patients. Coumadin requires regular monitoring, and poses certain lifestyle restrictions. More recently, the development of NOACs, including Dabigatran (Pradaxa), Rivaroxaban (Xarelto), and Apixaban (Eliquis), allowed more flexibility in our approach. However, not everyone should switch from Coumadin to NOACs. Coumadin (Warfarin) is cheap, effective, and reversible. However, its onset of action is slow, often taking 3 or more days to become therapeutic, and requires regular monitoring of INR levels. Coumadin interacts with multiple medications and food items, and its therapeutic level can be difficult to achieve. Nonetheless, those individuals already on Coumadin with stable INR levels, or who have chronic renal disease that may interfere with processing of NOACs, may do better on Coumadin long term. Additional considerations against NOACs include cost of NOACs and twice daily dosing (Dabigatran, Apixaban). Reversibility of NOACs is also a concern. At this point there is no established antidote for patients who are bleeding or require emergent surgery, and there is a paucity of evidence to guide the clinical care during these situations. Currently, some evidence exists to support the use of four factor prothrombin complex concentrate, a blood product, in urgent situations, for reversal of NOACs. As of now, the largest comparison of NOACs & Coumadin is a metaanalysis study published in 11/2013. The study analyzed data from more than 70,000 patients, and concluded that NOACs are at least not inferior to Coumadin. All 3 commercially available NOACs agents appear more similar than different, and when each NOAC agent is compared to Coumadin, they appear slightly superior to Coumadin. Specifically, use of NOACs resulted in less strokes overall, especially less hemorrhagic (bleeding type) strokes compared with Coumadin, and resulted in less overall mortality. The risk of GI bleeding, however, is higher with NOAC patients. It is important to emphasize that the overall statistical difference of above findings are slight between NOAC and Coumadin populations. No head to head comparison exists among the NOAC agents with each other, and therefore one cannot make assertion regarding superiority of any one NOAC agent over another. -Kai Sung, M.D., F.A.C.C., F.H.R.S. Page 4 www.tricitycardiology.com 2nd Quarter 2014

Tri-City Cardiology Introduces Dedicated Vein Center Facility Tri-City Cardiology is proud to present the newly opened Vein Center located at 6402 E Superstition Springs Blvd., Ste 224 in Mesa. The Vein Center is comprised of a team of Board Certified physicians in Vascular Medicine and Interventional Cardiology dedicated to the evaluation and treatment of venous disease. They will work with each patient to recommend a specialized treatment plan based on the condition and extent of their venous disease. The Vein Center provides comprehensive services to treat venous disease including: Venous Ultrasound (mapping) Compression Stocking Fittings and Sales Radiofrequency Ablation for Venous Reflux Disease (VNUS) Sclerotherapy The goal of the physicians and staff of the Vein Center is to help each patient have a positive experience with optimal outcomes that help patients return to an active healthy lifestyle. If you experience discomfort, pain, or swelling in your legs, ask your cardiologist if you are a candidate for the services offered at the Vein Center. For an appointment with a Vein Center Specialist, call 480-835-6100. Leaders in Cardiovascular Excellence... Where Patients Come First. 2nd Quarter 2014 www.tricitycardiology.com Page 5

Amy Wood is the Supervisor of the Anticoagulation Clinic and Triage Departments of Tri-City Cardiology. Amy is a Registered Nurse with extensive experience in Cardiovascular Nursing. She obtained her undergraduate degree from Burge School of Nursing/Drury University and completed her post-graduate studies at the University of Florida. Over the course of her career Amy has held several national certifi cations specifi c to cardiology. She served as the Clinical Nurse Expert for the American Heart Association, has met with members of the US Congress to discuss legislation specifi c to heart healthy initiatives, and is a published author. Amy s diverse clinical background includes working in the Coronary Care Unit, the Cardiac Cath Lab, and the Electrophysiology Lab. She has received numerous honors and awards for her leadership in nursing. Hydration Strategies for Hot Weather The arid desert of Arizona requires planning and preparation to maintain hydration. Failing to properly hydrate can result in dizziness, fainting, digestive problems, and even heat stroke. Common signs of dehydration, though often nonspecific, include fatigue, mental fogginess, loss of appetite, flushed skin, heat intolerance, light-headedness, dark colored urine. How to Avoid Dehydration According to the American College of Sports Medicine, to avoid dehydration you should drink at least 12-20 ounces of fluid one to two hours before an outdoor activity. After that, you should consume 6-12 ounces of fluid every 10-15 minutes that you are outside. One easier way to ensure properly hydrated is to check your urine. If it is clear, pale or light straw-colored, it is OK. If the urine is darker in color, keep drinking! Not All Beverages Are Created Equal: Some hydrate, others dehydrate Some beverages are better than others at preventing dehydration. Water is all you need if you are planning to be active in a low or moderate intensity activity, such as walking, for only an hour or less. If you plan on exercising longer than one hour, or if you anticipate being in the sun for more than a few hours, you may want to hydrate with a sports drink. Sports drinks replace not only fluid, but also electrolytes such as sodium and potassium, which are lost through perspiration. Alcohol or caffeinated beverages, such as coffee, teas, and colas, are not recommended for optimal hydration. These fluids tend to cause diuresis and promote dehydration. Fruit juices and fruit drinks may have too many carbohydrates or too little sodium. If you are going to drink fruit juices, you may want to try diluting them with about 50% water. Adequate hydration will help keep your summer activities safer and more enjoyable. -Amy L. Wood, R.N. 2nd Quarter 2014 www.tricitycardiology.com Page 7

Heather M. Duquette-Wolf is a Registered Dietician and Certifi ed Specialist in Sports Dietetics. She received her degree in Food Science and Nutrition from Plattsburgh State University of New York. She completed her post graduate work in nutrition at Yavapai County Medical Center in Arizona. Heather is the owner of HMD Nutrition, has developed and taught nutrition courses for a therapeutic college and is a nutrition consultant for the Internal Revenue Service as well as Glendale and Phoenix Fire Departments. She continues to consult and lecture for private, corporate and medical communities. Heather consults at the Baywood, Dobson, and Gilbert offices. Brain Power Salad (Spinach Salad with Salmon, Avocado and Blueberries) Prep Time: 10 minutes Total Time: 10 minutes Yield: 2 servings Salad Ingredients: 8 ounces smoked salmon, roughly chopped 1 avocado, peeled, pitted and diced 4 cups baby spinach (or mixed greens) 1/2 cup fresh blueberries 1/4 cup light feta or blue cheese crumbles 1/4 cup chopped walnuts (optional) half a red onion, thinly sliced honey chia seed vinaigrette Toss all ingredients together until combined. Drizzle or toss with vinaigrette. Honey Chia Seed Vinaigrette Ingredients: 1/3 cup olive oil 2 Tbsp. apple cider vinegar 1 Tbsp. chia seeds 1 Tbsp. honey 1/4 tsp. salt Whisk all ingredients together until combined and emulsified. Page 6 www.tricitycardiology.com 2nd Quarter 2014

Convenient East Valley Locations 1520 S. Dobson Rd., Ste 209, Mesa AZ 85202 6750 E. Baywood Ave., Ste 301, Mesa AZ 85206 2680 S. Val Vista Dr., Bldg 15, Ste 185, Gilbert AZ 85295 37100 N. Gantzel Rd., Ste 202, San Tan Valley AZ 85140 Vein Center 6402 E. Superstition Springs Blvd., Ste 224, Mesa AZ 85206 Main Phone: (480) 835-6100 Central Fax Number: (480) 461-4243 Website: www.tricitycardiology.com The physicians and staff at Tri-City Cardiology Consultants look forward to providing patients and their families with very good care and service.