PHILADELPHIA INTERNATIONAL MEDICINE® NEWS BUREAU
Contact: Leonard N. Karp
lkarp@philadelphiamedicine.com
215-735-3989
December 19, 2003

In this month's edition:

1. Temple’s Pulmonary Hypertension Program Improves Diagnosis and Treatment
2. Penn Study Finds Physicians Should Prescribe Cholesterol-lowering Medicines More To Select Patients While Still Hospitalized
3. Nation’s First Hospital Opens 21st Century Critical Care Complex

Temple’s Pulmonary Hypertension Program Improves Diagnosis and Treatment

Philadelphia – Temple University Hospital cardiologists and pulmonologists have created a new program exclusively for patients with pulmonary hypertension -- The Temple Pulmonary Hypertension Program. The program, located at the Temple Lung Center, offers a highly integrated approach to the management of this complex disorder. Temple University Hospital is a member of Philadelphia International Medicine.

Pulmonary hypertension is notoriously difficult to diagnose. Whether primary or secondary, the disease often has progressed quite far by the time symptoms—such as breathlessness with exertion, fatigue, or other signs of right heart failure—first appear. Some patients live only one or two years after diagnosis.

Recently, however, the treatment options for pulmonary hypertension have expanded. Notable new therapies such as prostacyclin, endothelin receptor blockers, and lung transplantation now offer many patients hope for improved quality of life and longer survival. The new program at Temple helps bring these new treatment options to international patients.

“Because of the difficulty of diagnosis and the severe consequences of this disease, physicians need to maintain a high level of suspicion for pulmonary hypertension,” says Gilbert D’Alonzo, DO, pulmonologist and co-director of the Temple Pulmonary Hypertension Program, along with cardiologist Howard Eisen, MD. “In particular, we need to be aware of the settings where it is most likely to occur, such as in the connective tissue disorders, or in lung disease, with valvular or hypertensive heart disease, or with sleep apnea.”

But diagnosing the presence of pulmonary hypertension is not enough, according to Dr. D’Alonzo, who points out that determination of the specific underlying cause is critical.

“I have seen many cases where a patient thought to have primary or idiopathic pulmonary hypertension actually had secondary pulmonary hypertension due to scleroderma, an interstitial lung disease, chronic obstructive pulmonary disease or heart disease,” says Dr. D’Alonzo.

An imprecise diagnosis can lead to missed treatment opportunities. A patient with pulmonary hypertension due to chronic thromboembolic disease, for example, usually can be treated with excellent results with a thromboendarterectomy. But if this patient is given a presumptive diagnosis of primary pulmonary hypertension—based perhaps on echocardiogram findings alone—and then treated medically, the opportunity for a highly effective surgical cure is lost. In this case, a ventilation-perfusion lung scan and pulmonary angiography would have identified the embolic obstruction and helped in surgical planning.

Although this is an extreme example, it illustrates the Temple Pulmonary Hypertension Program’s goal of identifying and treating the specific underlying causes of the disease. For this reason, all patients in Temple’s program will undergo a comprehensive diagnostic evaluation.

Once the underlying cause is determined, an evidence-based, individualized treatment plan is developed, selecting from among various potential therapies. The plan is administered and monitored in partnership with the referring physician.

For example, calcium channel blockers work only in about one of every five patients with the primary form of pulmonary hypertension; thus the likelihood of success with vasodilators must be tested during catheterization. Nonresponsive patients may benefit from prostacyclin (via continuous infusion or subcutaneously) or bosentan (an oral endothelin receptor agonist). These highly effective newer therapies, however, also typically require insurance pre-approvals, training of patients and close monitoring for side effects.

Other patients with pulmonary hypertension may benefit from anticoagulants, digoxin, diuretics, bronchodilators or supplemental oxygen. Select patients with severely symptomatic disease may be candidates for lung or heart-lung transplantation.

With the increasing complexity of therapy for pulmonary hypertension, a multidisciplinary approach to patient management is essential. Merging all essential services and facilities at one location in the Temple Lung Center means that patients in the Pulmonary Hypertension Program do not need to shuttle from clinic to clinic or laboratory to laboratory.

For patients who require a heart or heart-lung transplant, transfer to Temple’s successful transplantation programs is seamless. Also, as appropriate, patients gain access to the latest pulmonary hypertension clinical trials of new drugs. The creation of the Temple Pulmonary Hypertension Program provides improved coordination of care and expanded clinical services that keep pace with rapidly evolving therapeutics. From the initial consultation through treatment and follow-up visits, referring physicians are kept completely informed about their patient’s status and options.

Penn Study Finds Physicians Should Prescribe Cholesterol-lowering Medicines More To Select Patients While Still Hospitalized

Although cholesterol-lowering agents have been shown to dramatically reduce the likelihood of cardiovascular diseases, few people who qualify for these drugs actually receive them. A joint study of the University of Pennsylvania Medical Center and other hospitals, published in a recent issue of Archives of Internal Medicine, suggests that increasing the appropriate use of cholesterol-lowering therapies – while the patients are still in the hospital – could translate into improved clinical outcomes.

Herbert Aronow, MD, MPH, assistant professor of Medicine at the University of Pennsylvania School of Medicine, and researchers at the Cleveland Clinic studied more than 2,100 patients at nearly 70 United States and Canadian hospitals undergoing heart angioplasty in the EPILOG trial.

The researchers asked the question: ‘If patients with cardiovascular disease are hospitalized, does it matter whether cholesterol-lowering agents are begun before discharge or whether that decision is deferred to the outpatient setting?’ They found two things: first, patients who started the medicine while in the hospital fared better than those who didn’t; and second, those patients who started the medications while in the hospital were more likely to continue using the drugs following discharge.

“The bottom line is that we need to capitalize on the opportunity to initiate these life-saving medications in the hospital when our patients are most motivated to alter their lifestyle or medical regimens,” said Dr. Aronow.

“The findings were remarkable,” he continued. “Patients who were started on cholesterol-lowering agents while hospitalized were nearly three times more likely to be taking these medications in follow-up than those who went home without them. Given the well-established benefits associated with cholesterol-lowering drugs and the high prevalence of cardiovascular disease, any strategy that leads to increased drug utilization could have a tremendous impact on our societal health.”

Atherosclerosis, the build-up of fatty deposits (‘plaque’) inside the body’s arteries is the leading cause of death and disability worldwide. This disease is responsible for most heart attacks and strokes and ultimately leads millions of patients worldwide to undergo heart angioplasty and bypass surgery each year.

“Cholesterol-lowering agents, such as statins, reduce the chances of dying, having a heart attack or stroke or needing angioplasty or bypass surgery by roughly one third,” said Aronow. “Nevertheless, recent surveys revealed that only one to two-thirds of eligible patients are prescribed these medications. Further, among those taking these medications, most are on too low a dosage to be clinically effective.”

He also cautioned that, “despite the substantial health benefits attributed to these medications, they are no substitute for a healthy lifestyle. Diet, exercise and smoking cessation are the cornerstones of prevention and should be considered as complementary to, not in place of, medical therapy.”

Nation’s First Hospital Opens 21st Century Critical Care Complex

Pennsylvania Hospital, in continuous operation for 252 years, built a 22,000 square foot expansion on top of an existing building on the historic campus with no disruption to patient care. An open house to celebrate the completion of the 45-bed Pease Critical Care Complex was held on December 16, 2003. Some notable facts about the project include:

• Pauline Pease, a volunteer and member of the hospital Auxiliary, left an unexpected bequest of $20 million to the hospital in 2001, in honor of the "personal touch" she observed at the hospital. The new complex is named in her honor.
• Nurses, physicians and staff worked with the architects to design the optimal facility for cutting edge technology as well as the personal touch that Miss Pease admired. For example, the staff evaluated and selected the computer terminals as well as the emergency breakaway doors for patient rooms. They determined how the outlets for oxygen, electricity and other monitoring devices would be arrayed on the wall by the bedside for most efficient patient care. They even chose the custom-designed toilet facility in each patient room.
• The historic campus of the nation's first hospital is surrounded by the residential Philadelphia neighborhood. Bound by geography, hospital leaders had to build up, rather than out.
• A series of bridge-style trusses supports the three new floors over the existing Widener Building. Seismic codes required zero shifting of the foundation; so eight-ton columns were bored into the bedrock in the Emergency Room. The expansion complements the existing buildings and anticipates the possible future for hospital facilities.
• The new complex features self-contained private patient rooms, a oversized patient transport elevator, consultation rooms for physicians and families, state-of-the-art monitoring systems, card-controlled secure access and education and teaching areas for staff.

Philadelphia International Medicine is an organization that provides medical and patient support services to international patients. It also provides continuing medical education and health care training and education to international physicians, administrators and other practitioners. As the international department of several Philadelphia-area hospitals, international patients gain access to physicians and hospitals rated among the best in the world through one telephone call to PIM. You can reach PIM by calling 1-215-735-3575; fax, 1-215-790-1267; or e-mail, physicians@philadelphiamedicine.com . You can find out more about PIM through its Website at www.philadelphiamedicine.com .

Philadelphia International Medicine Listing of CME and other Course Offerings