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Heart Failure (Dr. Taylor 7/19/12)

Tuesday, July 17, 2012 - Noon


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. Dr. Taylor answers your questions about Heart Failure.

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Heart Failure

Peppy: After diagnosis of heart failure, what is the usual life span? Is there anything that can increase life span and quality of life beyond the usual medications?

Dr__Taylor: This depends on the severity of the heart failure at the time of diagnosis. Heart failure severe enough to cause hospitalization usually leads to an average survival of 4 - 5 years. However - the average survival of patients with mild heart failure while less than normal can easily be beyond 10 years.

Patients who respond favorably to medical therapy can achieve almost normal life expectancy.

The best survival is in patients who take the current standard medications recommended by the Heart Failure guidelines.

charlene-b: My husband was diagnosed with diastolic heart failure. Can you tell me what that means in comparison to other heart failures?

Dr__Taylor: Systole refers to the contraction of the heart and diastole to the relaxation and filling of the heart. Diastolic heart failure is an expression used to describe the state of heart failure when the heart muscle is not actually "weak" (has normal systole) but is actually too "stiff" (abnormal relaxation and filling). There are many possible causes and the treatments are similar to those for heart failure from weak heart muscle (systolic heart failure). It is just as serious a disorder and should be treated aggressively.

Miley: My mother has not been feeling well and she went to the doctor. After many tests they told her heart muscle is week and only functioning around 20%. What does that mean? What would be the treatment for that? We are not sure what to do? She has a cardiologist – but should she go to a heart failure cardiologist?

Dr__Taylor: Please see the response previously to Charlene B. Your mother has what we would call systolic heart failure because her pumping function is reduced. That is what the 20% refers to. Her heart is only ejecting 20% of the blood that is in it with each beat. A normal heart pumps approximately 60% of the blood that it is in it out with each beat.

The treatment would involve several medications including beta blockers; angiotensin converting enzyme inhibitors; fluid pills or diuretics; and perhaps others.

Most cardiologists can effectively treat this type of heart failure - but if she fails conventional treatment, a consult with a heart failure cardiologist may be necessary to explore other advanced options.

Peppy: I understand there are increasing cases of preserved systolic function heart failure among women. Is this true and if so why?

Dr__Taylor: The diagnosis of preserved systolic function heart failure is increasing. It is debatable whether the incidence is increasing or if we are better at diagnosing it.

It is true that women are more likely than men to have this type of heart failure for a variety of reasons.

Men are more likely to develop their heart failure earlier in life due to coronary heart disease (CHD/CAD). Women survive longer than men in general and develop their heart failure later, often without having CAD.

Peppy: Do you think the increased use of statins is causing a weakening of the heart muscle and leading to more heart failure? I've read that statins might be the cause of many cases of heart failure.

Dr__Taylor: This is a very insightful question and currently controversial.

Presently we do not have clear evidence that heart failure is caused by statins or statins make heart failure worse.

There is also no evidence that statins are helpful for heart failure in the absence of high cholesterol.

I do not believe that statins directly cause heart failure as you state. Therefore statins should only be given for patients with heart failure if they have other clear indications for statins such as abnormal lipids, coronary artery disease and other risk factors for coronary heart disease.

gj45: Would a patient with CHF also have some problems with confusion and short term memory loss?

Dr__Taylor: It is not uncommon for patients with heart failure to have problems with memory and confusion.

Sometimes this is directly related to the heart failure itself since the amount of blood pumped to the brain could be decreased.

Sometimes it is simply related to normal aging changes since heart failure is more common in the elderly.

Peppy: I've read that having a non-stemi puts you at great risk of heart failure within 5 years. Is this true?

Dr__Taylor: Yes - heart attacks whether they have EKG evidence or not cause heart damage and any cardiac damage puts you at risk for heart failure in the near future.

Symptoms of Heart Failure

claudiaf2_1: Is it possible to feel mild chest pains because of dilated cardiomyopathy?

Dr__Taylor: In short - yes - it is possible, but not typical.

hastont: I had a heart attack 4 months ago, doctor changed my meds and took me off of htcz I had been taking for a long time, it became more difficult to breath so it was switched back 1 week ago, is that a sign of CHF. I did have a code stemi MI, I am 49

Dr__Taylor: While shortness of breath may be a sign of heart failure certainly heart failure is not the most common cause of shortness of breath.

A more thorough evaluation of your heart function, physical exam and review of symptoms would be necessary to confirm the diagnosis of congestive heart failure. You should discuss this further with your physician.

KarenMi: My grandmother has heart failure. She does well for a while and then has shortness of breath and swelling in her feet. Is that normal? Why don't her medications hold her longer?

Dr__Taylor: Heart failure is a chronic disease subject to periods of improvement and worsening.

Why these periods occur is not completely understood. Sometimes it is due to the patient's inability to follow the prescribed medical and dietary recommendations. Sometimes it is due to other ongoing medical problems and sometimes it is simply due to worsening of the underlying heart, lung or kidney function.

Frank: My brother was diagnosed with cardiomyopathy. Does that run in families? Should I get checked somehow? What are the signs?

Dr__Taylor: Cardiomyopathy can run in families. It is estimated that up to 30 - 40% of cardiomyopathies are inherited. Current recommendation is that for a patient with cardiomyopathy who has another family member with cardiomyopathy that all of the first degree relatives (siblings, parents, and children) be tested for cardiomyopathy. Unless there is another member of your family other than your brother with cardiomyopathy, then we would not recommend routine screening for you.

CasetJY: I have cardiomyopathy since the birth of my child in 2000. I am beginning to have premature menopausal symptoms and would like to explore hormone replacement therapy - what are your thoughts on this?

Dr__Taylor: This is a very good question but one which we do not have any good scientific evidence one way or another. Certainly there is no clear information suggesting that hormone replacement therapy (HRT) is significantly harmful for patients with cardiomyopathy. Likewise there is no good data suggesting it is helpful.

However I have numerous cardiomyopathy patients taking HRT for a number of indications and they have done quite well with it.

MatthewJ89: Is it possible to have cardiomyopathy, had heart failure and blood test for heart failure is negative and still have symptoms, even with beta blocker, lasix,vasotec, coumadin for a-fib and stroke. Heart little enlarged, leg and ankle edema.

Dr__Taylor: Unfortunately the symptoms of heart failure including shortness of breath, edema, fatigue are also caused by a number of other disorders and are occasionally even side effects of the medications used to treat heart failure and other diseases such as diabetes.

One should discuss the side effects and symptoms with your physician as it is quite difficult to tease these out on this web chat.

Medications for Heart Failure

claudiaf2: Are larger doses of carvedilol and ramipril more likely to stall the progress of cardiomyopathy? Why might doctors be reluctant to up the dose? What are the dangers of higher doses?

Dr__Taylor: The current recommendations are to increase the drugs like carvedilol and like ramipril to the maximum tolerated target doses which were established in the experimental trials.

Sometimes the doses can not be increased due to side effects but there are no specific dangers of higher doses in the absence of side effects.

Peppy: If we have to take a statin should we also take COQ10? Is COQ10 proven to help with statin side effects and preventing heart failure? If you have heart failure would COQ10 help with long term survival?

Dr__Taylor: There are anecdotes of patients taking CoQ10 and improving the statin side effects such as leg cramps and muscle and joint pains, however no good clinical trials proving its efficacy.

Likewise, there are small anecdotal trials of using CoQ10 in heart failure independent of statin use, suggesting benefit but no proof. Therefore, I often recommend the addition of CoQ10 in my heart failure patients who are suffering side effects from the statins but do not routinely recommend it for all patients with heart failure or for all patients taking statins.

claudiaf2: If one is having no other side effects, is a low pulse rate (45-50) during sleep period a deterrent to increasing the dosage of meds?

Dr__Taylor: Not necessarily - pulse during sleep, unless it is severely depressed, much lower than you describe, is not necessarily dangerous.

KJK: Are there any medications or supplements you can take to improve the heart function – I have heard of CoQ10 and also hawthorn extract can help with heart failure patients. What do you think?

Dr__Taylor: Although not extensively studied to date, current small studies do not suggest either of these or any other supplements improve cardiac function. Therefore, they are not currently recommended for heart failure or heart disease in general. Please see my previous comments about CoQ10 specifically.

claudiaf2: do you count slow pulse rate (50 or 45) as a dangerous side effect of meds?

Dr__Taylor: A pulse rate of 45 - 50 is not necessarily dangerous if it is stable and the patient has no symptoms. However, if the slow pulse is related to other symptoms, such as lightheadedness, dizziness, severe fatigue - then perhaps decreasing the dose of beta blocker might be helpful.

Mymoms: My mom has recently been diagnosed with heart failure. Are there specific medications she should be on?

Dr__Taylor: See Miley's response for more information on medications to take for heart failure.

B-type natriuretic peptide (BNP)

AnnB: My mother's BNP was 550 fasting. She is 75 and has fatigue but does not seem to be in heart failure that I know of. What would the treatment be?

Dr__Taylor: We have received a couple questions about B-type Natriuretic Peptide (BNP). BNP can be measured by several techniques so the actual testing type is needed to interpret a result. If the test only measure BNP, then the normal range is less than 100 but as we age the normal level increases so we often see patients with normal hearts who have levels up to 500 or more, particularly women over the age of 70. If the test measures, a part of the molecule, N-terminal BNP or Pro-BNP then the normal can be up to 400-500 and as above we see elderly pts with normal hearts and levels up to 1000 or more.

If BNP is elevated due to heart failure it may stay elevated even after treatment and improvement in symptoms. It may be rechecked at times to compare results but in-and-of-itself does not "diagnose" heart failure, nor directly guide therapy.

Niuer: Can you please explain BNP and how it is used to detect heart failure. At what level is hospitalization required and how often should it be checked in patience with cardiomyopathy.

Dr__Taylor: BNP means B-type natriuretic peptide. It is a protein secreted by normal heart muscle cells but is secreted in excess in heart muscle cells under stress.

Therefore, patients with heart failure or having an acute heart attack will have increased blood levels of BNP.

Please see my response to Ann B earlier for more discussion about BNP.

In addition there is no absolute cut off as to what level requires hospitalization, what level is good or bad, or what is normal for someone with cardiomyopathy. Obviously - lower is better but some patients with chronic heart failure have elevated levels despite having good control of their symptoms.

Heart Failure Surgery

hughW: does your cardio have extensive experience in the following procedures. if so, which doc? LEFT VENTRICULAR RESECTION left ventricular (LV) infarctectomy, thrombecytomy. left ventricular (LV) infarctectomy aneuresectomy.....resulting from an M.I. IN 1999. HIGH FUNVTION. EF AT 45%. not experiencing. heart failure, yet

Dr__Taylor: We have extensive experience with left ventricular (LV) aneurysmectomy as well as left ventricular remodeling surgery for non-aneurysms. Currently the only accepted LV surgery for advanced heart failure is aneurysmectomy. LV remodeling surgery is a modification of the procedure for hearts that don't have a true aneurysm but have a large scar. It is sometime helpful but not routinely. An LV with an ejection fraction of 45% would be unlikely to benefit from LV surgery.

fran: Are there Cardiothoracic surgeons doing the wrap around procedure for heart failure patients. I am interested because patient is 70 yr old male with numbers suggestive of end stage heart failure but not yet psychologically ready to wear a Heartmate II. Would Cardiomyoplasty be an option for this patient?

Dr__Taylor: Currently cardiomyoplasty is not being performed for heart failure as it did not prove successful in small clinical trials.

Heart Failure Surgery - Heart Transplant

RobertC: I am a 68 year old Heart diseased patient who has had three heart attacks, two open heart procedures with eight by-passes, two stint procedures, recently under went another stint procedure and am told that there is not much left that can be done. I recently had a defibrillator & pacemaker and it seems that the medical team have reached a "give up attitude". How can one determine if a transplant is my only option and how can this become a reality if this is my only option.

Dr__Taylor: Transplantation may be an option for your advanced heart disease.

The risks and benefits of a possible transplant can only be assessed after a careful evaluation by a transplant center.

Often the center will review the current status of your heart perhaps obtain additional testing and then weigh the risks and benefits with you.

Being 68 years of age increases the risk of transplant therefore many centers exclude patients with advanced age. But the majority will consider patients at least up to age 70 if they are otherwise in good physical health.

lowerme: My cousin had a transplant a couple years ago. Now his new heart is having problems and he is in heart failure. Why would that happen?

Dr__Taylor: The most likely explanation is that he is suffering rejection of the new heart. Therefore, the muscle is becoming weakened by the rejection and he has once again developed heart failure.

Left Ventricular Assist Device (LVAD)

heavyheart: Can you talk about the LVAD? My dad is 73 years old and now has bad heart failure. I am wondering if there are age limits on it. How do they select someone to get these devices?

Dr__Taylor: LVAD or Left ventricular assist device is the type of device that former Vice-President Dick Cheney had for almost 2 years before his heart transplant procedure.

It can be an effective treatment for patients with severe and advanced heart failure when no other options are available. They have been successfully used in elderly patients, some even in their late 70's and early 80's.

It is a somewhat risky procedure so careful evaluation of the potential candidates other organs and medical disorders is necessary.

CRT (cardiac resynchronization therapy) or Bi-ventricular Pacemaker

Kennedy: I have heard of a biV device is good for heart failure patients. But when I suggested it to my doctor. He said that was not for me. What is it and why is it good for some people with heart failure and not with others?

Dr__Taylor: Some heart failure patients who have systolic heart failure (low ejection fraction -- weak heart muscle) develop problems with the conducting system of the heart. It takes longer for the electrical impulse to cross from one side of the heart to the other and that causes the muscle to beat out of synch.

A special type of pacemaker can be implanted to simultaneous pace several areas of the heart to make the muscle contract more normally. This is often referred to as a bi-v device or more commonly a CRT (cardiac resynchronization therapy).

What your doctor was perhaps referring to either you did not have slow electrical conduction through the heart or the heart muscle was not weak enough or out of synch enough to potentially benefit from the device.

Stem Cell Therapy for Heart Failure

wpiper: Is it possible for Stem Cell therapy to improve coronary heart disease and heart failure?

Dr__Taylor: Stem Cell therapy is currently experimental yet the results are encouraging for both coronary heart disease and heart failure. It is far too early to recommend these therapies as routine.

JacksonFL: Do you have any stem cell trials? If stem cells are not the next answer for heart failure - what's coming down the road for people with a bad heart muscle?

Dr__Taylor: Stem cells may be helpful in the future. However, currently the most exciting development for heart failure is the newer left ventricular assist devices. They are becoming smaller and less complicated - and easier to implant.

RichT: Good Morning: I was inquiring as to whether or not you may have some heart stem cell clinical trials going on at any of your locations and looking for volunteers? You may have me in your files, I have been checking for about 4 to 5 years now. Time is beginning to be my enemy and hopefully you may be able to help. Thank you for your consideration Respectfully, RichT

Dr__Taylor: There have been many questions about stem cell trials - please go to the website, sponsored by the NIH and leading in research involving heart failure and stem cells; They will provide information on multiple centers throughout the country.

ressee: What is going on with stem cell therapy? What types of research is going on for heart failure?

Dr__Taylor: see above.

Cancer and Heart Failure

Fate81: My aunt had cancer and has been in remission for several years. I think that her heart has been damaged by the chemicals given to her during her treatment. She is now having shortness of breath and her ejection fraction is 38%. What can be done for her? She has done so well for so long. Is this it now?

Dr__Taylor: Chemotherapy can damage the heart muscle. The effect is not always seen right away and can be seen even many years (or decades) after the treatment. Luckily the heart often will respond favorably to the same treatments we use for hearts damaged by heart attacks, valve problems, viruses and even genetic (familial) diseases. She should see a cardiologist and receive appropriate treatment for her cardiomyopathy (abnormal heart muscle).

Valve Disease and Heart Failure

clara: I have had aortic valve and grafts operated on, and 7 grafts the last 4 years. Now the mitral valve is moderate and the tricuspid valve has gone to severe. I am told that I am at a high risk for heart failure. Can you explain this to me.

Dr__Taylor: Chronic severe valve disease makes the heart muscle work harder than normal. That extra work and stress on the heart can lead to the development of heart failure in the future.

Jenny: If you have both atrial fibrillation and mitral valve prolapse, can they lead to heart failure? Also asked: If atrial fibrillation and mitral valve prolapse can lead to heart failure, what tests should be done to prevent that? Can one condition be a symptom of the other?

Dr__Taylor: Atrial fibrillation can cause heart failure if the heart rate during atrial fibrillation remains excessively elevated (i.e. greater than 130 beats per minute)

Mitral valve prolapse can lead to heart failure if the MVP causes severe mitral regurgitation (leak).

Well controlled atrial fibrillation and MVP without significant regurgitation should not directly cause heart failure.

Patients with heart failure often develop atrial fibrillation which can make things worse.

shih_tzu_rules: I was diagnosed with heart failure last year, I then had heart valve surgery, my questions are; Do I still have heart failure?, I live in Denver and am worried about the altitude, how does it affect my heart?

Dr__Taylor: If the heart failure was only related to the valve abnormality and the heart muscle function is now normal after surgery, then you should not still have heart failure.

However, if the heart muscle was permanently damaged by the prior valve abnormality, then you at risk for continued or future heart failure.

Living in Denver lowers the oxygen to your heart but for the vast majority of people, this is not a problem. It can be a problem for patients with advanced heart and lung failure that have lower than normal oxygen levels to begin with.

Sarcoidosis and Heart Failure

CaroleN: I have sarcoidosis. I am getting arrhythmias - PACs, PVCs and have been feeling more tired and winded. My doctor wants me to see a cardiologist to be evaluated for cardiac involvement. Who should I see at the Cleveland Clinic?

Dr__Taylor: Sarcoid can affect the heart as well as other organs. There are several doctors at the Cleveland Clinic who specialize in Sarcoidosis both in the Pulmonary division and the Cardiology division. One can simply call the appointment number and specify that the consult is for possible cardiac Sarcoidosis and they will arrange the visits with the appropriate cardiologist. 800-223-2273, extension 46697.

Blood Pressure and Heart Failure

katers: I have high blood pressure. I try to control it but it has been a battle for many years. I read that it can cause heart failure - how long does that take?

Dr__Taylor: Hypertension especially poorly controlled is a risk factor for heart failure. However, it can be quite unpredictable. Patients may go years or sometimes decades before hypertension leads to heart failure. Despite this it is extremely important to aggressively control your blood pressure to decrease the chances of developing heart failure or stroke or coronary disease.

Diet and Exercise

claudiaf2_1: How radical is a low-sodium diet supposed to be? How much harm does eating out occasionally in a restaurant do to someone with CHF?

Dr__Taylor: Not radical. It is primarily a less than 2 gram sodium diet which is in fact not very radical. To occasionally deviate is not necessarily harmful but to deviate frequently i.e. several days in a row or multiple days in a week – or to an extreme - can be harmful.

DanniV: Hi. My husband has been diagnosed with heart failure due to a virus. His EF is 42%. We have had conflicting information about exercise. Can he exercise? He was fairly active; road his bike long distances, played tennis, ran. Can he do any of these if he is on his medications?

Dr__Taylor: Even with severe cardiomyopathies (EF less than 20-25%), exercise is beneficial. However, despite what you may think, one cannot "train the heart into improvement, 'make a Lance Armstrong heart' by heavy exercise. In fact, extreme exercise can make things worse. However, low level aerobic exercise for extended periods, frequently can improve symptoms and delay need for hospitalization and progression. This level of exercise should be such that 30-45 minutes can be performed 4-6 days per week but during which one is not severely short of breath. I use the ability to talk as a fair marker. If one cannot talk during exercise it is too strenuous. The exercise method is less important and can include walking, riding stationary or regular bicycle, treadmill, elliptical, etc. Running is possible but I generally discourage that extent in pts with cardiomyopathy.

claudiaf2: In the case of asymptomatic moderate cardiomyopathy (caused by chemotherapy), how does one know how much exercise to get? Walking seems to be fine. How about swimming? What are the dangers of over exercising?

Dr__Taylor: Please refer to DanniV's question that was just answered.

claudiaf2_1: Thank you. This has all been very helpful.

Reviewed: 07/12

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