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By Valentin Fuster, MD, PhD
for WebMD Health
Chest pain, 911, sirens, the emergency room; These are the images you think of when you hear the words "heart attack." But as frightening as this sounds, your prospects today for avoiding or surviving a heart attack are improving almost by the minute. Nearly two-thirds of people who have heart attacks now survive, and half the people who would have died of a heart attack 10 years ago survive today.
Why? Much of the progress is due to new drugs -- blood thinners, cholesterol-lowering drugs, and clot-busters -- some of which can be administered on the way to the hospital. New technologies are upping the heart attack survival rate even more. Patients are also helping themselves; heightened awareness of what symptoms may mean a heart attack has led people to call for emergency help more quickly, boosting their chances of survival. Let's look at several recent developments that may improve your odds if a heart attack comes looking for you.
Smart Stents
One of the breakthroughs of the decade is something called a drug-eluting stent. Most people know that stents are tiny mesh cages placed into arteries to keep them open so that blood can pump through them. But what if another blockage forms? Drug-eluting stents slowly release a drug that prevents your arteries from renarrowing. In two ground-breaking studies, none of the patients with on of these "smart" drug-releasing stents had any new blockages in their arteries, compared to about 25% of patients without them. The first drug-eluting stent, which releases an antibiotic called sirolimus, was approved by the FDA in April 2003, and nearly half a million have already been implanted in patients. In late 2003, there was some concern that drug-eluting stents might be associated with an increased rate of dangerous blood clots, but after extensive review, in October 2004 the FDA announced the rate of such odds appears to be no higher with these stents than with any other.
In late 2004, the FDA also approved a second drug-eluting stent; instead of sirolimus, this stent releases a drug called paclitaxel. Found naturally in the Pacific Yew tree, paclitaxel is also the active ingredient in the chemotherapy drug Taxol. Given in much smaller, time released doses through the stent, it regulates cell accumulation and prevents repeat blockage of the arteries
Imaging
In another exciting development, we can now take MRI and CT images of your heart when you're in your 30's and 40s and predict where you'll have calcium and cholesterol deposits that may clog your arteries and cause a heart attack 15 to 20 years later. Through an MRI technique developed by our group at Mount Sinai along with other institutions, we've been able to create highly detailed images -- first of the brain, helping us to predict strokes before they happen -- and now of the heart. Another type of MRI looks directly at the blood as it rushes through the vessels of the heart, telling us where the arteries are starting to narrow when the blood becomes "pinched" into smaller quarters. And yet another new technique, ultra-fast CT, lets us see the state of the coronary arteries by injecting contrast material into your arm. If the ultra-fast CT tells us your coronary artery is in trouble, we can focus in using an MRI. These new imaging techniques have evolved simultaneously, and they will help us diagnose heart disease without surgery, long before you're ambushed by a heart attack
A Vaccine Against Heart Attack?
One of the most important things we've learned within the past year or so has been that inflammation plays a critical role in atherosclerosis, the hardening of the arteries caused by accumulation of fatty deposits that leads to coronary artery blockage and, ultimately, heart attack. This provide us with some exciting new possible targets for treatment and prevention of coronary artery disease. For example, recent studies have shown that lowering the levels of a substance called C-reactive protein, a marker of inflammation found in the blood, cuts the risk of heart attack even in people who have normal cholesterol levels.
In the future, we may also be able to target the inflammatory process in order to develop a vaccine to prevent heart attacks. Early studies have found that vaccinating mice with certain kinds of proteins designed to activate the immune system against inflammation helps protect them against the development of atherosclerosis.
Stem Cells and Genetics
Can you imagine of your heart could be told to repair itself? That isn't science fiction -- it's likely to be a reality within the next few years, thanks to stem cell research. Several recent studies have found that some of the cells in our heart can multiply by themselves if they have the proper trigger. This means that heart cells could possible be stimulated to regenerate new cells and repair scarred tissue. This exciting area of research is moving rapidly but may take a number of years to be available to patients.
We're also learning more about the role that genetics plays in heart attacks. Studies have found that mutations in a number of different genes can be associated with an elevated risk of heart disease, including heart attack. This year, new studies identified several more such genetic variations, including the first common gene that's associated with both heart attack and stroke. Another study, the first large-scale, genomewide search for heart attack susceptibility genes, found at least one other new genetic area of susceptibility. Taken together, these and other genomic advances move us closer to a tantalizing goal; the cloning of a gene that will help us prevent heart attacks and other types of heart disease.
Statin Drugs
Aside from being revolutionary, these developments have something else in common; they're very expensive. Technology saves lives, but it's also costly. Not every heart attack prevention tool, however costs a lot of money. In November 2001, one of the largest studies ever conducted, the Heart Protection Study, reported that statin drugs, designed to lower cholesterol, reduce the risk of heart attacks and strokes by more that one-third for people who have a high risk of coronary artery disease. These patients benefited from the particular statin used in the study, even if they didn't have high cholesterol levels to start with. Since then, studies continues to confirm the importance of statins for lowering cholesterol and, consequently, the risk of a heart attack. And research published in 2004 has shown that patients who are given a statin drug within 24 hours of having a heart attack do significantly better than those who don't receive the drugs until later. If we could put an extra million high-risk people on statin drugs, we could save 5,000 lives every year.
These advances, together with previous progress, means that thousands of people can survive heart attacks that would have killed them five years ago, or avoid a heart attack entirely.
Now, we need to make sure that such advances are available to the patients who desperately need them. As our ability to predict, prevent, and treat heart attacks continues to improve, we must find ways to use competition, simplified devices for less complex cases, and targeting of high-risk patients to make sure we can help the greatest number of people with these revolutionary new tools.
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