When Oprah speaks, people listen. Her influence runs the gamut from cosmetics to presidential candidates, from book clubs to health issues. When the star turned her spotlight on heart disease, undergoing a diagnostic scan and highlighting the technology on her program, legions took note.
But some Wisconsin viewers were ahead of the curve. Froedtert Hospital and the Medical College of Wisconsin, thanks to a partnership with GE Healthcare, were the first in the world to receive the technology Oprah featured on her show. Called the 64-slice CT scanner (CT stands for computed tomography), the machine allows doctors to noninvasively examine the coronary arteries for disease. The technology has continued to develop rapidly, and the medical community is still working to integrate it into patient care. In a country where heart disease is the No. 1 killer of men and women, there’s no doubt that multidetector CT scanning has the ability to revolutionize cardiac care.
“The CT technology was really driven because of the prevalence of heart disease and the need to have better diagnostic tests to noninvasively image the arteries,” explains Dr. David Marks. He is an associate professor of medicine specializing in cardiovascular medicine and radiology at the Medical College and a cardiologist at Froedtert. Previously, the only commonly available option for a doctor who needed to look closely at a patient’s coronary arteries was heart catheterization. Although that procedure is safe and accurate – the “gold standard” – it is invasive: The doctor inserts a narrow plastic tube into an artery in the patient’s groin or arm and advances it up into the coronary arteries.
The advent of the 64-slice CT scan means doctors could potentially access the same information with a considerably less invasive test. Along with Dr. Dennis Foley, professor of radiology at the Medical College and section chief of digital imaging at Froedtert, Marks conducted a clinical trial of the 64-slice CT scan at Froedtert to compare its accuracy with that of heart catheterization. Although the trial’s results are still being analyzed, Marks notes, “the bulk of the data suggests, in the appropriate patients, it is a very accurate technology.”
Because the heart is always moving, it long presented a challenge for CT imaging. Previous versions of the technology could successfully take pictures of static organs, but couldn’t keep up with the heart. “Imagine trying to take a picture of your dog running across your front yard. If your camera’s not fast enough, then your dog is a blur,” explains Dr. Robert D. Lyon, director of cardiac CT at Columbia St. Mary’s Hospital.
By offering improved speed, quantity and quality of detectors, the 64-slice CT scanner produces clear, three-dimensional images of the coronary arteries. Patients take medication to slow down the heart (beta-blockers) and are injected with a small amount of X-ray dye before undergoing the scan. “I can not only see that there’s disease, but how much disease. I can not only assume that there’s blockage, but I can be sure whether there’s blockage, and how much blockage is present,” notes Dr. Bruce W. Cardone, medical director and owner of Lakeside Diagnostic Imaging Center.
Meanwhile, the experience is a whole lot more comfortable for the patient. One of Foley’s patients, 67-year-old Velayudhan Nair, had a 64-slice CT scan of his heart at Froedtert Hospital a few years ago. “It was a piece of cake,” he says of the test. “The major advantage is I don’t have to go and get my groin blood vessel punctured and put a catheter all the way up to my heart.”
The test was also potentially life-saving, revealing that Nair had a 30 to 50 percent narrowing of one of his coronary vessels. Although immediate surgery wasn’t required, the test allowed his doctor to begin to treat the condition by putting him on heart medication. “The narrowing of the blood vessel is reversible if you take the proper medication,” Nair notes. He’ll continue on his course of treatment for a few years, then repeat the study to see what’s happened.
By the time he goes in for his next scan, it’s possible the technology will be even better than the first time around. Since the initial introduction of the 64-slice CT scanner, innovations and improvements have occurred at a rapid pace. “We’re all working in a field where technological developments are occurring very quickly. There’s obviously a real commercial incentive for companies to keep pushing the envelope,” notes Lyon. Already, he says, there’s a 256-slice CT scanner on the horizon.
Some of the technology’s latest versions work to improve upon limitations of the 64-slice CT scan. With the faster dual-source 64-slice CT scan, for example, patients don’t need to slow their heart rate with beta-blockers. This means patients with asthma, emphysema or other breathing conditions, who can’t take beta-blockers, are now eligible candidates for the scan. The dual-source CT can also be used for very obese patients who were difficult to image with less powerful machines. Depending on the patient, it’s possible to cut the radiation dose with the dual-source scanner, notes Lyon. Right now, Columbia St. Mary’s is the only hospital in the region to possess this type of scanner.
Who Should Get A Scan?
Despite the technology’s benefits, it’s not for everyone, and it does come with some risks. Multidetector CT angiography “really has been a huge addition to my tool kit or the things that I use to help take care of my patients,” says Marks. “But today, it hasn’t replaced any of those tools that I use. And in fact, it requires physicians to be even more thoughtful and even better trained.” The key, he emphasizes, is “using the right test, at the right time, in the right patient.”
For example, a patient who is having a heart attack absolutely should not have the CT scan, says Marks. A heart catheterization is a much more appropriate choice because it has therapeutic as well as diagnostic capabilities that can save a person’s life right then and there, whereas a CT scan is simply diagnostic. Likewise, Marks says he would question the use of multidetector CT for patients who have no heart problems whatsoever and are simply looking for a screening test.
“There’s a difference between a diagnostic test and a screening test. What you’d like in a screening test is you’d like it to be inexpensive, you’d like it to be safe, and you’d like to make sure that you identify everyone at risk,” Marks explains. “Right now, because it is still an expensive test and because it involves radiation, I would say it is still a diagnostic test rather than a screening test.”
Lyon agrees. “I would never recommend [multidetector CT] as a screening examination to a patient, no matter what the risk factors are.” In his practice, the exam is reserved for patients who have symptoms such as low-risk chest pain or who have had another test that is equivocal but suggests they have significant coronary artery disease. “It’s somebody who you’re not sure of what the issue is, but you really don’t want to cath them because the risk of an invasive test outweighs the benefits you would receive,”Marks says of the latter group. The test can also be appropriate when doctors need to know a patient’s coronary anatomy – in the case of an upcoming surgery, for example, notes Marks.
The care with which medical professionals determine who is and is not appropriate for CT coronary angiography underscores the sort of tight rope they’re walking right now between clear technological advances and their potential risks.
The 64-slice CT “is a marvelous technology. I don’t want to take anything away from it. But as a medical profession, we’re still finding out where it fits in the spectrum of patient care to both optimize care and minimize radiation,”
As CT scanning has become more and more common, so have public concerns about excessive radiation. Last summer, a study published in The Journal of the American Medical Associationindicated that 64-slice CT angiography may increase lifetime cancer risks, especially in younger, female patients. Media outlets ranging from The New York Timesto the Milwaukee Journal Sentinelhave picked up on the concern, not just as it relates to the heart, but for all of CT’s imaging purposes.
“Too much radiation is a big subject in the lay press right now and it’s something we are acutely aware of,” says Lyon. “We’re not cavalier about that at all.” Over time, he says, doctors’ clinical understanding of the best uses for the technology will continue to improve, and the devices themselves will continue to get better and safer. In the meantime, he urges, “Let’s not forget about the benefit of these tests.”
And clearly, the benefits are tremendous. With heart disease in particular, the ability to detect a blockage in a patient’s coronary artery without being invasive and before she has a cardiac event would have seemed the stuff of science fiction not too many years ago.
Yet it’s also comforting to know that, even as our technological capabilities grow in leaps and bounds, it’s still people who make the difference. For Nair, the patient who underwent a 64-slice CT scan a few years ago, finding a provider he trusted was the most important thing.
“People should go to a dedicated center which does this kind of work. When the technology comes up, everybody wants to have one of them, but it all depends upon who does the procedure and who interprets the procedure.”
Beyond the abundance of cutting-edge technology in Milwaukee, patients will find thoughtful and capable providers, quietly leading the way.
Caroline Goyette, a former assistant editor for Milwaukee Magazine, is a freelance writer based in New Orleans.
New guidelines for Alzheimer’s.
Vitamin E is no longer a recommended treatment for dementias like Alzheimer’s, according to new guidelines by the American Psychiatric Association. Studies haven’t shown consistent benefits from vitamin E, and large doses pose health risks. Anti-psychotic drugs are no longer recommended for most Alzheimer’s patients, either. But nondrug treatments that focus on emotional well-being, as well as medications for depression, have mostly been effective in treating symptoms.
Dos and don’ts for helping alcoholics.
How do you help alcoholics cut down on drinking? The anti-convulsant gabapentin (Neurontin) may help, reports the Journal of Clinical Psychiatry. On the other hand, trazodone (Desyrel), a mild, sedating antidepressant, made it more difficult for recovering alcoholics to stay away from drinking. Trazodone is commonly given to alcoholics to help them sleep during detoxification, but appears to increase alcohol cravings, according to a study presented at an American Academy of Addiction Psychiatry meeting.
No chest pain? It could still be a heart attack.
Women are less likely than men to experience chest pain during a heart attack, according to a review of 69 studies in the Archives of Internal Medicine. Instead, women may have pain in the middle or upper back, shortness of breath, difficulty breathing while lying down, indigestion, nausea or vomiting, weakness and appetite loss. In fact, up to one-third of heart attack victims don’t experience chest pain, and the older you are, the less likely you’ll have chest pain.
Elective C-sections may cause infant lung problems.
The newborns of women who had an elective Caesarean near term – rather than vaginal birth or emergency Caesarean – were more likely to have serious lung problems. So says a study reported online in BMJ (British Medical Journal). The risks were reduced if the elective C-section was performed after 39 weeks of gestation. It’s possible that labor itself triggers hormonal and physiological changes needed for lungs to mature properly, and that those changes are not present during elective C-sections.
Depression: You can feel it in your bones.
A new study in the Archives of Internal Medicine showed that depressed women were more likely to have significant bone loss than a healthy control group. The risk of bone loss in depressed premenopausal women was similar to that of women who smoke or have low calcium intake. As the body reacts to the stress of depression, it produces additional hormones that can lead to thinning bones – and possibly osteoporosis. The report prompted a specialist to recommend that even women with mild depression receive bone mineral density screening.
– Scott R. Weinberger