FROM THE HEART

November 11, 1998
		Although heart disease remains the leading cause of death in the U.S., researchers appear to be making gains in the treatment and prevention of the condition. Following a background report, Phil Ponce talks with two doctors about their work to combat the disease.

April 13, 1998: Smoking and Heart Disease June 19, 1997: Estrogen and Heart Disease April 3, 1997: Heart Disease risks More NewsHour Health coverage.           The American Heart Association The official site of the Scientific Sessions RealAudio of an interview with Dr. Valentin Fuster	ELIZABETH FARNSWORTH: Now, new research on heart disease. We begin with some background from Susan Dentzer of our health unit, a partnership with the Henry J. Kaiser Family Foundation.
	Tracking a killer
	SUSAN DENTZER: Since 1910, heart disease has been the biggest single killer of Americans. It now causes almost half a million deaths and costs an estimated $175 billion each year in health care outlays and lost productivity. A rarity in previous eras, heart disease is a 20th century affliction that stems largely from fattier diets, bad habits like smoking and couch-potato lifestyles. The good news is that healthier living and new treatments like drugs are already pushing down the death rate from heart disease. And at this week's annual convention of the American Heart Association in Dallas, researchers unveiled dozens of breakthroughs that could make deaths from heart disease a rarity again in the 21st century. The results underscore that the war on heart disease will have to be waged on multiple fronts. Take prevention. It's long been known that increased physical activity can reduce the risk of heart disease and stroke. But new research unveiled this week showed that vigorous exercise can even help people who already have heart disease drastically cut their risk of recurrent heart attack and deaths. It's also been known for several years that one to two glasses of red wine per day can lower rates of heart disease -- but until this week, it hasn't been clear why. Researchers at the AHA reported that it's probably the grapes used in winemaking that make the difference, rather than the alcohol. They found that plain old bottled grape juice actually discourages platelets in blood from clotting and helps to widen the body's blood vessels. But far and away the most excitement in Dallas stemmed from news about genetic treatments for cardiovascular disease. These techniques could augment or even replace today's conventional therapies, such as costly heart bypasses and angioplasties that as many as a million Americans undergo each year. The potential savings to the health care system could be tens of billions of dollars annually. Researchers reported that injecting extra copies of a gene called VEG-F into the heart produces a protein that prompts the growth of new blood vessels. That can overcome the arterial blockages that cause heart attacks and chest pain. In effect, a person could be helped to grow his or her own bypass in what is being called a "bio-bypass." Dr. Ronald Crystal of Cornell Medical School in New York City is one of the lead researchers. DR. RONALD CRYSTAL: What we're doing essentially is what the body does naturally. And all we're doing is giving a boost to the heart so that it makes more of this protein and can build its blood vessels. SUSAN DENTZER: Dr. Jeffrey Isner of St. Elizabeth's Medical Center in Boston has tried the technique on patients with clogged blood vessels and damaged hearts. DR. JEFFREY ISNER: In this group of patients what we observed was the development of new blood vessels that we could actually see with an angiogram. This collection of vessels here, those were not apparent a year before. SUSAN DENTZER: The results of early trials of the procedure have been so impressive that researchers plan to begin testing it soon on a large sample of patients at a number of medical centers across the country. ELIZABETH FARNSWORTH: Phil Ponce has more. PHIL PONCE: With us now, Dr. Ronald Crystal, whom we just saw on Susan Dentzer's piece, Professor of Medicine at Cornell University Medical School in New York City, and Dr. Valentin Fuster, President of the American Heart Association. He's the director of the Cardiovascular Institute at Mt. Sinai Medical Center in New York City. Gentlemen, welcome.
	The bio-bypass breakthrough
	Dr. Crystal, just to make sure that we have it clear, one can, and you have induced the heart to grow new blood vessels and, in effect, create its own bypass? DR. RONALD CRYSTAL, Cornell University Medical Center: Well, it's still early, and too early to tell whether it really works. Large-scale trials will have to be carried out. But the concept is to use genes the body normally uses when we're embryos and babies, to grow new blood vessels in the heart, inject those directly into the heart, to tell the heart to make its own blood vessels to get around areas that are clogged up. PHIL PONCE: And is this something that would be useful for somebody before, or after that person has heart disease or a heart attack? DR. RONALD CRYSTAL: Well, after large-scale trials are done, and we know that it works and that it's safe, we see it as a possibility for adjunct to bypass surgery, to angioplasty or opening up arteries with catheters, and possibly by itself as well, perhaps even earlier, to prevent these other major methods from being used. PHIL PONCE: Doctor, you tried it on a group of patients. What kind of results did you see, and what - what impact did it have on these people? DR. RONALD CRYSTAL: Most importantly, we've shown that genetic modification of the heart for a brief period of time - for the human heart - is safe, and that's very, very important. In terms of whether it works or not, the numbers are too small to be definitive, the trends certainly are in the right direction, and now large-scale trials in 1999 will be carried out in many different centers throughout the country to determine whether or not it really works. PHIL PONCE: But give us an example of how it affected the people that you worked with. DR. RONALD CRYSTAL: Well, the patients, of course, many of them better; they say they have less pain, and they can do more, and some of the tests are consistent with that. But, again, the study's too small to be definitive, and that's why we have to do what are referred to as control trials, so we can determine whether or not it really works. PHIL PONCE: Dr. Fuster, your reaction to this development? DR. VALENTIN FUSTER, Mt. Sinai Medical Center: I think Dr. Crystal's comments, which are very - to be cautious, but I think this technology is very, very promising. I think what it has been shown in this meeting of the American Heart Association is that genetic therapy in making new vessels is very safe, and I think this is important at this time. PHIL PONCE: But there's also a question about the long-term impact. Does anyone know if this is - if the improvements that have been seen in the - admittedly small group that Dr. Crystal talked about - that those are going to be long-lasting? DR. VALENTIN FUSTER: We do not know, and certainly this can only be known with the scrutiny of good trials, and follow patients for a long period of time. I suspect that in about two or three years we will know the answer.
	Who are the candidates?
	PHIL PONCE: And Dr. Crystal, people who would be candidates for this, again, just to clarify, people who - for example, people who have already had bypass surgery and for some reason can't have that kind of surgery again, this could conceivably be helpful? DR. RONALD CRYSTAL: The initial trials have been carried out in individuals who together with bypass surgery in areas that can't be bypassed, for individuals who have had bypass surgery and atomically we can't do the bypass surgery again, and also individuals as we get more information that it's safer and safer, then we'll be able to move that to individuals earlier and earlier, and perhaps even before they have these other procedures. PHIL PONCE: Dr. Crystal, you talk about these trials that are going to be taking place. How does one get to participate in something like that? Just luck? DR. RONALD CRYSTAL: Well, it'll be announced at various medical centers and of the large medical centers around the country, we'll be doing these kinds of trials, and their doctors can know the physicians carrying out these trials, can refer their patients to the trials.
	Physical activity and grape juice
	PHIL PONCE: Dr. Fuster, one of the studies had to do with physical activity. It's long been know that physical - at least there's been a connection between physical activity and overall good health. What new has been learned? DR. VALENTIN FUSTER: A breakthrough, I believe, is defined by the group at Harvard that patients with myocardial infarction or heart attacks engaging in an exercise program two to four days a week, a rather vigorous program, can decrease new heart attacks and death by nearly 40 percent over a period of five years. I think this is a very spectacular finding. PHIL PONCE: And is that because - what - some doctors have been reluctant or fearful to put patients who've had a heart attack through a rigorous exercise program? DR. VALENTIN FUSTER: I think we have been cautious, and this is why we learn slowly, and I think this finding may be surprising, is very important. PHIL PONCE: Dr. Crystal, when Susan Dentzer's piece was on the air and she was talking about the grape juice, the grape juice test, there was a smile on your face. Why is that? DR. RONALD CRYSTAL: Well, whether grape juice will work or not, I think, again, you have to do trials and see. PHIL PONCE: Some skepticism on your part, though? DR. RONALD CRYSTAL: I think some skepticism, but that's because it's early, and I think studies have to be carried out to determine whether or not, in fact, it would be useful. PHIL PONCE: Dr. Fuster, your reaction to the grape juice findings? DR. VALENTIN FUSTER: Well, the finding shows that blood clotting is decreased but there is no information at all about whether or not this helps people.
	The state of the war on heart disease
	PHIL PONCE: And, Dr. Fuster, you've personally done some work on a new way of looking at plaque in the arteries. Describe that to us briefly. DR. VALENTIN FUSTER: Well, one of the challenges that we have is to identify the individuals who are prone to heart attack or to a stroke before they develop these events, and up until now we didn't have any technology that was able to give us this information. With magnetic resonance imaging at our institution we have been able now to identify not only the individuals that are developing disease of the arteries and may be predisposed, for example, to stroke, but at the same time we can see if the disease is so-called benign or is malignant, and in the patients that we feel that the plaques that we see directly non-invasively, this is like an X-ray, that they have this plaque's prone to rupture, to lead to a blood clot - a blood clot and to a stroke - we have been able to change treatment in such patients, and I can see in the future rather than an individual stopping smoking at the time of a heart attack, he may stop smoking at the time that we can tell such individual, you are developing disease and the disease is malignant, as we can see with this new X-ray type of technique. PHIL PONCE: So, Dr. Fuster, before this new imaging technique, one had to - one had to what - perform surgery in order to see how bad the plaque was in artery, how bad the substance was that was blocking the artery? DR. VALENTIN FUSTER: Well, we didn't have really technology. The most - the gold standard is what we call coronary angiography, which is to inject material into the coronary arteries and then you see the degree of narrowing, but now we have learned over the last few years that the degree of narrowing has nothing to do with the predisposition to a blood clot and to a heart attack. So this new technology not only will make us able to see the degree of narrowing but most importantly, what is the composition of the plaque that can lead to the blood clot, and then we might modify therapy. PHIL PONCE: Dr. Crystal, in the very short time we have left, how is the medical profession doing in the fight against heart disease? DR. RONALD CRYSTAL: Well, it's moving along very strongly. We're reaping the benefits of the investment of our nation in biomedical technology and research over the years, and I think now with the information from the Human Genome Project we can put genes into hearts now, we can use this information to begin to really help people with heart disease. PHIL PONCE: Dr. Crystal, Dr. Fuster, thank you both very much.