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Heart Failure (Dr. Mountis 12/17/12)

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

Monday, December 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 important for people with heart failure to understand their treatment options - from medications to ventricular assist devices (VAD) and transplant. Heart Failure cardiologist, Dr. Maria Mountis answers your questions.

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Heart Failure Questions

rachelLD: Can you tell me the difference of right sided and left sided heart failure.

Dr__Mountis: The main causes of left sided heart failure are coronary artery disease; prior heart attacks; long standing high blood pressure; viruses. Patients with left sided heart failure may have a weak pumping chamber and symptoms may be shortness of breath; fatigue; angina.

Right sided heart failure may be secondary to left sided heart failure; or underlying lung disease. Patient’s symptoms with right sided heart failure may be swelling in the legs and in the belly.

The two types of heart failure can also coincide but it takes a careful exam and medical history to diagnose one or the other.

carduini: What is the definition and description of Heart failure?

Dr__Mountis: Heart failure is a combination of symptoms such as shortness of breath; swelling in the legs; fatigue because the heart is unable to pump blood effectively to the body. There are many causes of heart failure but the most common ones are high blood pressure and coronary artery disease leading to heart attacks.

Frank_CO: What is the difference between diastolic and systolic heart failure?

Dr__Mountis: Systolic heart failure means the left ventricle is not squeezing well and a patient will have a low ejection fraction. Common reasons for systolic heart failure are coronary artery disease; hypertension; valvular disease; viral cardiomyopathy; post-partum cardiomyopathy.

Diastolic heart failure is when the heart is unable to relax well and patients will have a normal pumping function of the heart. Examples of diastolic heart failure may be hypertrophic cardiomyopathy; high blood pressure as well; and infiltrative cardiomyopathy such as amyloid.

Both types of heart failure can have the same symptoms of shortness of breath and swelling.

NoraJ: My dad is in the hospital now for heart failure and his kidneys are not doing well. He is on a lot of medications and oxygen. Wonder if it is worthwhile to transfer him to Cleveland Clinic or if there are things I should ask to make sure his care is the best. Any thoughts?

Dr__Mountis: We see this often when the kidneys are not receiving enough blood flow from the heart and therefore can lead to temporary or permanent kidney failure. Patients may even need temporary dialysis in conditions like this but often if you can stabilize the heart function, the kidney function can improve as well. We would always be happy to review your father's case and welcome him as a transfer.

JoshK: In 2009, I was diagnosed with cardiomyopathy and heart failure. My doctor put in an ICD and I am on medications. I also started an exercise and diet program - I am feeling good and my EF has increased to 45% since the time I was diagnosed. I know I will always have the diagnosis of cardiomyopathy but if it is in control, is it still heart failure?

Dr__Mountis: That is an excellent question. I would always give you the diagnosis of cardiomyopathy and potentially you may be labeled as "chronic heart failure," but you are obviously very well compensated since you are able to function the way you do. Your heart failure symptoms are in remission. Glad you are doing so well.

Tanya1967: I am a 45 yo African American woman. I was diagnosed 10 years ago with cardiomyopathy and now have an EF of 15%. I am wondering what my options are. My doctors have had me on medications and it seems as though over the years things have progressed. Is LVAD an option, should I go to a transplant center hospital. What is the prognosis?

Dr__Mountis: Yes - I would absolutely be evaluated by a heart failure physician in a center that performs LVADs and transplants. Unfortunately, like in your case, there are patients whose heart failure continue to progress despite excellent medical therapy. You could potentially be a candidate for LVAD and/or transplant. We would be happy to see you.

nutzy: I am 67 year old female. In my childhood I had rheumatic fever. Ten years ago I have undergone a mitral valve replacement with a prosthetic one simultaneously with Maze procedure but the ATRIAL FIB. couldn't be stopped. I USED ALMOST all the antiarrhythmic drugs but everyone helped me for a while. Now I take a beta-blocker CONCOR 10MG twice daily; diltiazem 180mg daily; valsartan80mg; and Lipitor 20mmg. NO rate control and the drug interactions make me not feeling well almost every day. I'LL HAVE ON WENSDAY an echo test. What is important to ask the doctor after that? Do you have any information about my treatment? I want to know, maybe to change the calcium blocker with another drug? DO you have any advice for me? HOW could know what is my heart failure stage? BNI?

Dr__Mountis: Your case is a little more involved because of prior valve surgery and long standing atrial fibrillation. Once your echocardiogram is completed, please discuss with your electrophysiologist as well as with your cardiologist what the best course of action would be.

If you have any decrease in your ejection fraction, you would be labeled Stage C heart failure. With a lower ejection fraction, we tend to recommend beta blockers over calcium channel blockers. Please discuss more with your doctor.

estein: 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__Mountis: Excellent question. I would not just say the timing of diagnosis, but also what caused the heart failure is a very important question to ask. Being on standard medical therapy and living a healthy lifestyle are all very important to increasing lifespan and maintaining quality of life. It is important to maintain a low sodium (less than 2000 mg per day) and fluid restricted diet (less than 2 liters). Enrolling in a cardiac rehab program to give you lifelong exercise tools is also very important.

Heart Failure and Heart Attack

AnnieB: My dad had a heart attack. Right now his heart is at 25%. How long do they wait to see if his heart muscle will come back? And then what are the options for a 25% function?

Dr__Mountis: Many of our patients that we follow in our Heart Failure practice have an ejection fraction similar to your father's. Typical therapy for this includes medicines such as beta blocker; ace inhibitor and aldosterone antagonists. Many patients can live a very long life with an ejection fraction of 25%. If he has recurrent heart failure, then we may potentially have other treatments such as biventricular pacemaker; ventricular assist device or heart transplant.

johnk: I am 60 years old, exercised everyday; eat healthy, Cholesterol and BP great. Had an extensive myocardial infarction. Coma 4 days. My Lipoprotein (a) was 66 now 58 after 8 months of 2000 mg of Niacin--Any thing else I can do to lower it? My EF is 34 % Do you need a Heart Failure Doctor?

Dr__Mountis: Congratulations on being proactive with your health. I would want to know what the rest of your cardiac medications are - you should be on a beta blocker and an ace inhibitor to maintain your ejection fraction. You should follow closely with your primary cardiologist and it may be helpful to have a consult with a heart failure cardiologist at least once.

johnk: This is a follow up question. Before and after my Heart Attack I maintained a healthy lifestyle. Only my Lipoprotein (a) was very high. This secondary heart risk may have caused my problem. Are you aware of any new research to help lower my Lipo (a)? I have an ICD and do have A-Fib. My medicines are the following: Pradaxa, Coreg, Altace, Aldactone, Plavix, Aspirin, Lipitor and aspirin. Would a Heart Failure specialist be of benefit to me or just stay with a cardiologist?

Dr__Mountis: You are on an excellent medical regimen - I think you and your cardiologist have come up with a very effective plan for your cardiac care. Regarding your follow up on lipoprotein (a) I would recommend you see one of our Preventive Cardiology cardiologists.

elizabeth12: My husband had a massive heart attack at work. His heart is enlarged and they are getting him stabilized with medications. He has a lot of fluid on board, he has congestive heart failure. Is it possible his heart can go back to his normal size with time? Do you think if he has a physical job, he will be able to go back to work? Will he be able to exercise? He plays golf and tennis and runs.

Dr__Mountis: There are two issues right now. One is the acute phase of his heart failure with his excessive fluid, which needs to be stabilized first with diuretics and adjustment of his medications. : With excellent medical therapy, his heart function can potentially normalize but it will take time to see the difference. His doctors will need to follow him closely at first and then decide if it is safe for him to return to his work.

Yes - he should be able to exercise although it may be a modified regimen at first. Talk to your doctor about cardiac rehab, which may benefit him immensely.

Pacemaker Device for Heart Failure

suzanne1298: I have a friend that has heart failure - has been getting worse over the years. I heard of a pacemaker that can help people with heart failure. What are the criteria that you put in pacemakers for heart failure?

Dr__Mountis: When an individual has worsening heart failure it is best that they are evaluated by a cardiologist who specializes in heart failure. I suspect the device you are speaking of is a biventricular pacemaker, with the goal to synchronize the pumping function of the right and left side of the heart. Criteria include EKG and echocardiogram evaluation.

Ventricular Assist Devices for Heart Failure

charlesCL: What is the new device I saw on the paper for heart failure? how do you get to participate in the trial?

Dr__Mountis: The newest device that is approved for heart failure is called a ventricular assist device. This is a partially implanted device that helps assist the failing heart. It would be best to speak to your cardiologist about whether you qualify for this.

hfdave: Can lvads be placed in people who are not heart transplant candidates?

Dr__Mountis: Absolutely. Patients who are not transplant candidates but who have advanced heart failure and qualify for a ventricular assist device are implanted with the device as destination therapy. There are multiple reasons why an individual may not be a candidate for transplant such as age, a recent diagnosis of cancer, advanced kidney disease, advanced lung disease, poorly controlled diabetes. Each case is different and we would be happy to review your case to see if you qualify.

queenie37: Is it possible to have an LVAD placed while waiting transplant and then your heart gets better and you do not need either?

Dr__Mountis: Great question. What you are referring to is termed "myocardial recovery." We are very aggressive with trying to improve patient's heart functions with medicines and the LVAD. If we feel that an LVAD can be removed successfully and not need transplant, we can pursue this therapy as well.

Heart Transplant

SHHhMI: Hi. My niece has very advanced cardiomyopathy. She is in need of a transplant. I am wondering if it is possible to pick a center such as Cleveland Clinic if we live in Wisconsin. How far away is it a possibility to be listed and treated at Cleveland Clinic?

Dr__Mountis: We have many patients from throughout the country who have been evaluated and treated for heart failure. Insurance approval and distance are very important in listing for heart transplant. We would be happy to evaluate your niece and in cases where distance is an issue; some patients may have to move closer to the implanting center.

robert1023: Do you perform Total Heart Transplant whereby you remove the diseased heart and implant donor's heart or perform a partial ventricle transplant?

Dr__Mountis:  Cleveland Clinic is a very busy center with heart transplant. All transplants performed here have been complete heart transplants.

Stem Cell Therapy and Research

mauriceS: I had a heart attack on June 1, 2011. My heart stopped on the table as they were installing a stent. I am now operating on approx. 30% of my heart. I have heard of stem cell reproduction therapy. I wonder if this would be a treatment to make repairs to my heart? My doctor has not discussed this option. even though I have questioned him on the procedure. He just said it was not for me. Please let me know if there is any hope in this stem cell procedure. I turned 73 in NOV 2012 and am in excellent health, other than this one condition. Thanks Maurice.

Dr__Mountis: I am impressed you are looking into other options. Currently your best treatment would be evidenced based medical therapy; stem cell therapy is available at Cleveland Clinic but only in research trials and you would need to qualify for it. We could certainly review your case to see if you would be a candidate for stem cell therapy. Your doctor should optimize medial therapy including beta blockers, ace inhibitors and aldosterone antagonists and diuretics if needed.

hf-az-25:  Today I read about researchers programming ordinary heart cells to become replicas of heart pacemaker cells. Can you talk about some of the new research coming out that may help heart failure patients?

Dr__Mountis: Ongoing research for heart failure patients is diverse including new medications; stem cell therapy; and mechanical support therapy. Research in these fields potentially may take years to be implemented on a daily basis.

Activity, Exercise and Heart Failure

Caliguy23: I have an LVAD and my doctors told me I can walk - wonder to mix it up a bit if I can also ride a stationary cycle and also lift light weights?

Dr__Mountis: Absolutely. I would first speak with your doctor to insure that is appropriate from their standpoint. I recommend all patients attend cardiac rehab at first and once completed, then can pursue many forms of aerobic exercise. I also recommend only light weights (less than 20 pounds).

donnatz:  I have had a transplant for 10 years and knock on wood doing really well. I am going to relocate to Colorado where there is high altitude but worried this will affect my transplant and also ability to exercise. When I went there for an interview, I did notice shortness of breath and higher pulse. Is this normal? Will it get better with time?

Dr__Mountis: In relocating to a higher altitude location such as Denver, there will always be a period of time that you will need to acclimate to the altitude. That being said, there is a very active transplant center in Denver as well where they care for heart transplant patients. I would speak to your doctor about this.

Cancer and Heart – Cardio-Oncology

Julia33: My mother had cancer and has been in remission for several years. Despite the win, 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?

Dr__Mountis: You bring up an excellent topic. We are starting to evaluate many patients now who have undergone chemotherapy and have been cured of their cancer but due to potential side effects of the chemotherapy, some patients develop heart failure. We have a Cardio-Oncology Center that is run by my colleague, Dr. Oliveira, who would be happy to review your mom's case. In general, she should be on heart failure medication and monitored closely.

Risk for Heart Failure

TimD: My father died from congestive heart failure at the age of 63. He was also diagnosed with an aortic aneurysm. He was a heavy smoker up until his death. I am 48 and in good health & have never smoked. Am I still at risk for these conditions because of heredity? Thank you for your response.

Dr__Mountis: Smoking was definitely a contributor to your father's medical problems. I would recommend you have a baseline echocardiogram and abdominal ultrasound to insure that heart size and abdominal aorta size are normal. Continue to live a healthy lifestyle. Follow up with a cardiologist once a year for screening.

GaryT: 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 was told that I am at high risk for heart failure. Can you explain this to me?

Dr__Mountis: Another main etiology of heart failure is valve disease and with moderate mitral regurgitation and severe tricuspid regurgitation we may soon start to see failing of the heart and backing up of fluid, which are heart failure symptoms. I would certainly recommend that you be evaluated by a heart failure cardiologist to adjust medications and discuss any possible interventions.

Alcohol and Heart Failure

Adrian-C: I have an ejection Fraction of 37% , 68 years old, working, am very active ( run or bike 2-3 days per week and weight training 2 days per week), eat healthy, do not have a weight problem and drink 2-3 glasses of wine PER WEEK. Should I eliminate the alcohol completely? (I am in Columbus Ohio 3-4 time per year.)

Dr__Mountis: Without knowing the reason for your lowered ejection fraction it is hard to answer your question. The fact that you have a normal exercise tolerance indicates that your heart function is great. You should discuss this with your doctor.

WilliamNY: Hi. I have an LVAD and wondering what your thoughts are about alcohol. Can you drink a glass of wine with dinner in the evening?

Dr__Mountis: Every patient's case is different. In some cases alcohol can be the cause of heart failure and in those cases all alcohol should be avoided.

Dr__Mountis: If alcohol has never been a problem, then occasional consumption should not be a problem. Discuss with your doctor.


JonathanAB: What do you think about CoQ10 for heart failure? Does it have any impact on any of my other medications?

Dr__Mountis: CoQ10 is currently not recommended as standard medical therapy for heart failure. There is a very small subset of patients that may benefit from it. To my knowledge there are no negative interactions with other medications with CoQ10.

Reviewed: 12/12

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