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Heart Failure (Dr. Mountis 4/6/11)

Wednesday, April 6, 2011 - Noon

Maria Mountis, DO
Staff Physician, Division of Cardiology, Section of Heart, Failure and Transplantation, Miller Family Heart & Vascular Institute

Description

Heart failure affects an estimated 5.7 million Americans, and about 670,000 people are diagnosed with heart failure each year. It is also the leading cause of hospitalization in people over age 65. Take this opportunity to have your questions about Heart Failure answered by a cardiologist and a cardiac surgeon from the Cleveland Clinic.

More Information


Symptoms and Heart Failure

Robert: My wife has been diagnosed with congestive heart failure. She had her Aortic Valve replaced a year ago but doesn’t seem to be getting better. She has had several bouts with pneumonia and mucus builds up in her lungs when she sleeps at night causing her to wake up early coughing. She has to use oxygen at night and during the day when she gets short of breath. Is there anything your clinic can do to relieve her symptoms and help her return to some semblance of a normal life?

Dr_Maria_Mountis: Yes. Many lung symptoms that you are describing may well be congestive heart failure that has not been diagnosed or treated properly. I would recommend an evaluation including lab work, chest x-ray, EKG and echo for further diagnosis and management.

zfernandez: What role does microvascular angina play in heart failure?

Dr_Maria_Mountis: There is ongoing research at this time in looking into microvascular disease which can be seen for example in diabetic patients and in some women.  A common form of treatment is to carefully treat blood pressure


Diagnostic Tests for Heart Failure

Florence: Can an EKG pick up symptoms of heart failure? I am scheduled to have a blood test for BNP out of the blue. No one mentioned heart failure to me.

Dr_Maria_Mountis: An EKG can pick up electrical conduction abnormalities which may be a sign of an abnormal heart muscle but it is not the diagnostic choice of test for heart failure.

Your doctor may be concerned about heart failure that is why they are checking a BNP.  In order to diagnose heart failure there are other criteria including a physical exam and chest x-ray.

KateP: what are normal numbers for the BNP test (for Heart failure patients and non)?

Dr_Maria_Mountis: A BNP (not NT pro BNP) should be less than 100 for normal.  BNP levels are influenced by kidney function as well as weight - so it should be interpreted by a cardiologist before making the diagnosis of heart failure.

Longview546: What is the bnp test and how is it used to follow patients with heart failure

Dr_Maria_Mountis: BNP means beta naturetic peptide, which is a hormone released by the heart. It can be used as an adjunct marker to a physical exam in following patients with heart failure.

grannyc: Have had heart failure for 4 yrs....only had two BNP tests.....should I ask for another one? Last one was 575 two years ago

Dr_Maria_Mountis: BNP as an adjunct to a physical exam and other blood work - yes. But if you are feeling well - then I do not feel that it is absolutely necessary to check a BNP.


Evaluation of Heart Failure

Toni: My husband has Dilated Cardiomyopathy with an EF of 21% and is interested in coming to your clinic for 2nd opinion. Can you tell what your process would be, what would be the expected time he would be there, cost and just what to expect? Also, is there a place to stay there at your facility? Any information you could give is very much appreciated.

Dr_Maria_Mountis: We would need the records of your husband's obtained and sent in advance for review.  It would probably be a one day visit including meeting with one of the heart failure physicians, chest x-ray, echo, ekg and lab work and reviewing that data.  Depending on what we find, we may need you to come back for a second visit for more testing and treatment.

I would refer you to our financial advisers to discuss costs. We do have local hotels and a medical concierge to help you with travel and places to stay.

Lucille: Are second opinions a good thing when it comes to CHF?

Dr_Maria_Mountis: Yes - I think second opinions are always important.


Heart Failure and Medications

carol: The treatment for heart failure always seems to include a beta blocker. For some reason I haven't found one that doesn't affect me with major lung problems....congestion...wheezing and shortness of breath. In other words like a definite worsening of the heart failure. My EF is around 30 to 35% and would like to improve if possible...I currently take cozaar and aldactone along with toprol-XL....but have feeling I'll be off beta blocker soon. Any thoughts as to what I can also be taking that will help in keeping my EF at present or even bettering it? Thanks....love these live chats!! P.S. Had heart attack and valve replacement 4 yrs ago.....75 yrs old.............

Dr_Maria_Mountis: Currently you are on an excellent medical regimen including beta blocker, ARB and aldasterone antagonist. Some individuals do not tolerate beta blockers in high doses or if increased too quickly. You need to not be holding onto extra fluid in order to tolerate a beta blocker. Sometimes people need fine tuning with their volume status before tolerating a beta blocker.

Lucille: Already dx of CHF but seems like one 20 mg Lasix a week isn't enough

Dr_Maria_Mountis: Every patient has individual needs for the amount of diuretics and this should be discussed with your cardiologist.

mrag: How do you determine proper Toprol dosage? Is 100mg "better" than 50mg?

Dr_Maria_Mountis: The higher the dose that is tolerated - the better for the patient.

mrag: What does "tolerated" mean (in Toprol for example)?

Dr_Maria_Mountis: Tolerating this medication will mean your blood pressure and your heart rate are within normal limits


Heart Failure: Vitamins and Supplements

Kaye: Do you recommend supplements such as Co2 10 for CHF patients. I am on simvastatin drug. Last week cardiologist did EKG and showed the electric conduction in the right atrium area was delayed. I am trying to understand this. He said there was nothing I can do for it. But is there a supplement or something that would help? Hx of breast ca in 06 and LIMA to LAD and mitral valve repair in 6/08 thanks to Adriamycin. I would appreciate your input. Kaye

Dr_Maria_Mountis: At this point supplements such as coQ10 are not approved treatment through the American College of Cardiology for heart failure.  You should be following with a heart failure specialist because heart failure/cardiomyopathy due to adriamycin is a common condition that we follow.  Without seeing the ekg ourselves it difficult to say more than that.

Jack2560: I have been diagnosed with heart failure. I am on a cholesterol drug, aspirin, a beta blocker and something for my blood pressure. Are there certain pills that someone with heart failure should be on to prevent further damage? What about any special vitamins?

Dr_Maria_Mountis: The standard regimen used to treat heart failure are beta blockers, ACE inhibitors, aldosterone antagonists and maybe other medications as needed to treat the underlying cause of the heart failure.

Lucille: Do you recommend any supplements such as Co2 10 for CHF patients? I am on a statin drug. Last week cardiologist did EKG showing electric conduction delay. I am trying to understand this. Quick HX of 10/06 Inflammatory Breast Ca. Chemo, Surgery, more chemo then radiation. with use of adriamycin. 6/08 CHF with at least two MI damage. Triple bypass and repair of mitral valve in 6/08. Would appreciate your input. 9/15/10 showed RBBB. should I be on a beta blocker to improve the strength of the muscle?

Dr_Maria_Mountis: Answered question about COQ10 previously. Regarding beta blocker, yes - beta blockers are indicated for weakened heart muscles due to adriamycin


Heart Failure and ICD, Pacemakers

Martin: I have heart failure - newly diagnosed - my ejection fraction is 30% and my doctor wants to put in an iced - if this is a new diagnosis, isn't there a chance that the heart will improve and would not need it? also if I do need an ICD - shouldn't they evaluate me for a heart failure pacemaker too?

Dr_Maria_Mountis: Terrific question. Typically you want to be on maximally tolerated medical therapy for at least 6 months prior to implanting a defibrillator with helps of improvement in ejection fraction.  In certain cases it is necessary to implant an ICD - especially with lethal arrhythmias.  You may qualify for cardiac resynchronization based on your symptoms and EKG findings.

KT6783: I have a pacemaker, defibrillator and have had several heart attacks and stents. my doctor wants me to be on a blood thinner - not sure why - is that for the heart failure?

Dr_Maria_Mountis: You may have atrial fibrillation which is common to see in cases like you describe. But your doctor may also want you to be on a blood thinner to keep your stents and arteries open. Talk to your doctor about your questions.


Heart Failure and Heart Surgery, Heart Transplant, Ventricular Assist Device

KitKat5: My uncle had a heart transplant a few months ago. he is now in the hospital with transplant rejection. can you tell me what that is? is it serious?

Dr_Maria_Mountis: There are two type of rejection. Without knowing the full history - it is tough to comment. His immunosuppressant medications will need to be adjusted to help decrease future risk of rejection. It is not uncommon to see mild rejection in the first year after transplant.

Caren: I had a massive heart attack and then bypass surgery. this was all pretty recent last couple months. my ejection fraction is now 20%. I am wondering if that will improve with the bypass?

Dr_Maria_Mountis: There is a possibility that it may improve with time and medical therapy.

MollyC: My sister has been diagnosed with end-stage congestive heart failure. She was on the transplant list but now is not on it because of her other health problems. Would there be any other options available for someone like her?

Dr_Maria_Mountis: Many patients who do not qualify for heart transplant may be candidates for ventricular assist devices. She would need to be evaluated for this.

Jordan: uncle has ischemic cardiomyopathy, 25% E F and also diabetic - he is only 50 years old - should he be evaluated for a heart transplant

Dr_Maria_Mountis: Depending on his symptoms, he should be evaluated for advanced heart failure therapies including transplant, medications and ventricular assist devices.

Kelly: My mom is being evaluated for a ventricular assist device right now - she has been in the hospital. how many people go from vat to transplant and do they ever just keep the vat - she is only 54 years old.

Dr_Maria_Mountis: There are two indications for ventricular assist device (VAD) - one is bridge to transplant, which means the patient is too sick to wait for heart transplant and needs this device to get them to the time of transplant.  The other indication is destination therapy meaning that a patient may have other medical conditions that do not make them an ideal transplant candidate. On certain occasions patients can cross over from one indication to the other indication but only with close follow up would we know how they will do.

Frank: my good friend was diagnosed suddenly with cardiomyopathy and is now on a transplant list. This was so fast. How can your heart get so bad so fast? How do they know what heart is a good match for transplant? How long does this usually take?

Dr_Maria_Mountis: There are many reasons why someone can develop acute or sudden heart failure. Sometimes its a heart attack, other times it is a virus and some occasions it is an exacerbation of their long standing heart failure. An evaluation for heart transplant is very thorough and includes meeting with a cardiologist, surgeons, transplant nurses and social workers.

A donor heart is matched up to a recipient based on blood type, height, weight and antibody levels. There is a full team of individuals to ensure an appropriate match. The transplant evaluation process usually takes weeks to months in order for the transplant team to develop a working relationship with the patient and their support system. Every case is different.


Stem Cell Therapy

john: Can you talk about stem cell therapy for heart failure - I am wondering what type of trials are going on. Had a heart attack last year and my ejection fraction is 30%. Would like to do anything I can to help my future.

Dr_Maria_Mountis: That is a great question. We do have ongoing stem cell therapy trials at Cleveland Clinic - there are various inclusion and exclusion criteria. We would be happy to evaluate your information and refer you to our research coordinators.


Sleep Apnea and Heart Failure

wade: In the past I have had 3 MI and a triple bypass, I have also been diag. with sleep apnea with 15 out of the 17 apnea events being "central sleep apnea", is this possible a result of the Heart problem, or did I also have a heart failure sometime in the past during the Heart events?

Dr_Maria_Mountis: Sleep apnea is directly correlated to heart function and needs to be treated appropriately. Without knowing your full history it is difficult to answer the question although it is common to have heart failure accompany the diagnosis of an MI.


General Questions about Heart Failure

dfanderson: how do I know if I'm dying and what happens when you die from chf

Dr_Maria_Mountis: Heart failure does not necessarily mean a death sentence. With advanced heart failure the two most common problems are sudden cardiac death from an abnormal heart rhythm or pump failure. We have many available treatments for advanced heart failure including medical therapy, ventricular assist device therapy and heart transplant in the advanced heart failure patient.

Kate: can't you have right heart failure, too? or just atrial add/or ventricular failure?

Dr_Maria_Mountis: We classify heart failure into systolic or diastolic heart failure. When the heart either doesn't pump well (systolic) or doesn't relax well (diastolic).  Right heart failure is when the right side of the heart has weakened and symptoms may include swelling in the belly or legs. This may be due to either the left side of the heart not working well or underlying lung issues.

mrag: What is the long term (5 year) progression for CHF say in a 65 year old?

Dr_Maria_Mountis: It is hard to say without knowing certain pieces of information including symptoms, ejection fraction, or medications.

clara: I have read that having cardiovascular disease a person is at a higher risk for heart failure. I have had open heart surgery with grafts and now 4 stents. Could you explain the high risk?

Dr_Maria_Mountis: The most common cause for heart failure is coronary disease but if managed appropriately and keeping your grafts and stents open, there is a decreased risk of progression to heart failure.

grannyc: Was told I have non-sustained ventricular tachycardia....any treatment for that? Presently taking BP meds.

Dr_Maria_Mountis: Non sustained ventricular tachycardia is an abnormal heart rhythm from the bottom of the heart. You should have an evaluation to diagnose why you have it, In general beta blockers are the most common treatment but it would be wise to see an electrophysiologist who specializes in this.

mrag: Can you reverse heart failure?

Dr_Maria_Mountis: We can control symptoms of heart failure and with medical therapy we can improve the overall pumping function of the heart.

KolinJ: I have had several heart attacks. damage on the right side and front of heart with pulmonary hypertension. I have HF NYHA stage 3. what are my options?

Dr_Maria_Mountis: We need more information but your case is very typical of the patients I care for in the Section of Heart Failure and we would be happy to see you.

KateP: Depression can be more common in us CHF patients; do you think it can be because it may be side effects from some of the meds in addition to dealing with the sickness?

Dr_Maria_Mountis: Yes - beta blockers sometimes are not tolerated in patients and in those prone to depression, they may exacerbate the feeling.


Heart Failure and Pregnancy

Karen: I developed peripartum cardiomyopathy during my pregnancy. I am wondering if 1. will things get better with time after the baby is born and 2? will it affect the chance of future pregnancies?

Dr_Maria_Mountis: About half the cases of peripartum cardiomyopathy will get better with time and medical therapy and half may stay the same or possibly decline.  Medical therapy is needed to treat peripartum cardiomyopathy. At this point it would be advised to talk to a cardiologist prior to future pregnancy.

Jenna: My daughter had postpartum cardiomyopathy after delivery. her EF was down to 20%. Now 3 months later it is up to 40%. Any chance of it improving further back to normal? she has also been getting palpitations - and on a beta blocker - will these get better as her EF improves>

Dr_Maria_Mountis: It is a positive sign that her EF has improved within a short period of time with medical therapy. Beta blockers will help palpitations but other causes of palpitations should be looked into - including assessing thyroid function and decreasing any and all caffeine and alcohol consumption.


Diastolic Dysfunction

sibbjoann59: hello, I was diagnosed with mild ventricular diastolic dysfunction in October. I am a 58 yo female. I would like to know how to stop progression to heart failure. my doctor said it's not heart failure? My understanding is that I do have heart failure. Please tell me what I have, and what to do about it. thank you

Dr_Maria_Mountis: Diastolic dysfunction or heart failure is more common with age and in women. Diastolic heart failure encompasses symptoms of heart failure including leg swelling, shortness of breath, fatigue - but with a normal pumping function of the heart.  Treatment includes very close management of high blood pressure, diabetes, abnormal heart rhythms, and weight loss if needed.

sibbjoann59: would like to know if depression, grief and stress can cause mild ventricular diastolic dysfunction? I'm trying to find the cause of this recent diagnosis, but my doctor said to see a psychiatrist! please help me.

Dr_Maria_Mountis: We know that patients with heart disease may have an increased risk of depression but there is no correlation with diastolic dysfunction and this diagnosis. As we age, it is very common to see mild diastolic dysfunction.

sibbjoann59: you said that mild diastolic dysfunction is very common as we age, so how can I stop progression? My doctor isn't helping me. He just says to see a psychiatrist, but I want to know the rate of progression with age alone, and if my prognosis is better without any underlying cause other than normal aging. thank you.

Dr_Maria_Mountis: Without knowing anything else about your medical history it is tough to comment but I would be happy to see you.


Heart Failure and Exercise

clara: My husband had a silent massive heart attack - left ventricle. He is a diabetic and EF of 35. He now is exercising 6 days a week, controls diabetes and weight. Is it probably that he will heart failure?

Dr_Maria_Mountis: It is a wonderful sign that he is able to exercise 6 days a week. It will be crucial to continue exercise, managing his diabetes and taking his prescribed medications. EF (ejection fraction) is just a number and does not always tell how someone will do.

Reviewed: 04/11


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