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Heart Failure and Cardiomyopathy (Dr. Tang 8/17/10)

Tuesday, August 17, 2010 - Noon
Wilson Tang, MD

Wilson Tang, MD
Research Director of the Section of Heart Failure and Cardiac Transplantation Medicine in the Sydell and Arnold Miller Family Heart & Vascular Institute

Description

Cardiomyopathy is a growing public health issue that ultimately leads to heart failure, causing a quarter million U.S. deaths each year. With 3 million Americans currently suffering from the disease, patients MUST become better educated on the issue in order to catch it early, as it is known to provide no forewarning of its arrival. Dr. Tang, a cardiologist and Research Director of the Heart Failure and Cardiac Transplantation Medicine section of Cleveland Clinic, answers your questions about prevention and treatment, as well as reveal important information about the disease.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. W.H. Wilson Tang. We are thrilled to have him here today. Thanks for joining us Dr. Tang, let’s begin with the questions.

Dr__Wilson_Tang: Thank you for having me today.


Medical Management of Heart Failure

WilliamM: Originally diagnosed (1993) with CHF, cardiomyopathy and Atrial Fib. After years of medication with digoxin, beta blockers, ARB's and anti-arr. plus cardioversions the CHF and AF was managed. Also, now L & R atria and RV appear to be back to normal size, can I now consider myself to have reversed the cardiomyopathy?

Dr__Wilson_Tang: Seems that controlling the rate and medications have helped, and that's what these drugs do - halt and even sometimes reverse progression. But if you stop taking them or if heart rate is not in control it will relapse.


General Heart Failure Questions

CurtisRe: 2 questions for the online chat discussing cardiomyopathy and heart failure; 1) Briefly discuss the progressive nature of heart failure as it relates to cardiac remodeling and important actions patients can take at home to slow this progression. 2) What experience, if any, do you have w remote physiologic monitoring of patients with CHF as a means to reduce hospitalizations and ED utilization?

Dr__Wilson_Tang: Most patients continue to experience progressive symptoms, where the heart dilates and continues to get weaker with pressures elevated inside the heart. We do have an active program monitoring implanted devices in which some models have capabilities of measuring certain electrical signals that parallels with fluid retention, and we are actively recruiting patients to participate ongoing studies with pressure monitoring systems with implanted devices.

JerryH: what are the three most important things the patient can do to help the doctor treating heart failure?

Dr__Wilson_Tang: 1. Be compliant and maximize the medical therapies that can improve long term outcomes. this would include ace inhibitors or angiotensin receptor blockers, beta blockers, and if symptomatic, aldosterone receptor antagonists.

Dr__Wilson_Tang: 2. Maintain a low salt diet and exercise. Most patients believe that they are already compliant with that, but there is a lot of salt content in processed or ready made food and patients often neglect their aerobic regular exercise - rather than just being busy.

Dr__Wilson_Tang: 3. Follow regularly with your cardiologist. Heart failure no matter at what age and severity is a serious condition and even in improvement in heart function, patients can be at risk for adverse consequences or sudden cardiac death, so appropriate evaluation for eligibility for pacemaker and defibrillator is also warranted.

Bob: My wife was diagnosed with cardiomyopathy 2.5 years ago. With optimal medical therapy her EF had advanced from 12 to 35. She is class 1 with almost no symptoms. Question: She is scheduled for a routine colonoscopy. Are there any special precautions that should be taken with regard to anesthesiology used during the procedure?

Dr__Wilson_Tang: Colonoscopy is a low risk procedure. If a patient has no overt signs of congestion, he or she is likely to be able to undergo this procedure safely. The colonoscopy prep has high salt content but does not necessarily get absorbed into the blood stream. You should notify your wife's doctor prior to the procedure.

clara: How would one tell the difference between heart failure and mitral valve failure? I have had open heart surgery 4 years ago - bypass and aortic valve, 1 stent last year, and 3 stents 4 weeks ago. I have been told now that there might be a problem with the mitral valve. I am not sure I would recognize symptoms.

Dr__Wilson_Tang: They often present in a similar manner and in fact mitral valve abnormalities can occur in one of three scenarios.

Dr__Wilson_Tang: 1. It may occur if the supply of blood to the muscle controlling the chordae of the valve is diminished - we call this ischemic mitral regurgitation.

Dr__Wilson_Tang: 2. it may occur when your heart becomes bigger as the cardiac function deteriorates and the heart tries to compensate by a process called remodeling (where the heart enlarges and the valve leaflets do not meet).

Dr__Wilson_Tang: 3. The third one occurs where there is some structural abnormality of the valves that predispose them to have some mitral valve problems.

Dr__Wilson_Tang: All these three valve problems have medical and surgical treatments - but they are all treated differently.


Symptoms of Heart Failure

Cohn_A: I already have undergone 7 years ago MVR and Maze procedure. I tried most of the anti-arrhytmic drugs and had several cardioversion; stopped Amiodarone because thyreotoxicosis.For now I am in sinus rhythm taking Multaq and bisoprolol 10mg twice daily. I have read most of the medical information about this new medicine. I thought that all my tiredness and SOB symptoms are connected with the atrial fibrillations, but why? when I am in sinus rhythm? My EF is aprox. 60% but pulmonary blood pressure a little high(47%). had a dual pacemaker implant 2 years ago but this helped me only to take higher doses of medicine. I now there is not enough information but maybe you may recommend general direction of search in the future? CHF .pulmonary problems, drug interractions, vascular probl. Angyography 7 years ago was normal. Please ,tell me what I need to check first? Thank you for taking my question. Anita.

Dr__Wilson_Tang: First, there are many reasons why people have tiredness and shortness of breath. The fact that you have previous atrial fibrillation clearly focuses doctors on this condition. It is important to recognize that metabolic problems like thyroid disease, lung problems (which is a possible side effect of amiodarone), and other non-cardiac causes can also occur. Many patients even in sinus rhythm still have some symptoms despite a preserved ejection fraction. Sometimes, it can be attributed to increased stiffness of the heart more so than the impaired pumping function. Your elevated pulmonary pressure may be a result of that. Clearly understanding what the contributors to these abnormalities are may help doctors better titrate their drugs accordingly.

Dr__Wilson_Tang: You may want to consider an evaluation where they have a multidisciplinary evaluation of these potential contributors.

RuthC: I am a 73 year-old woman who was diagnosed in April with heart failure and placed on Coreg. My routine blood tests during the past two years show a low result for eGFR, currently 49; Creatinine, Serum is 1.09. Upon the least exertion, such as vacuuming, I sweat profusely and it smells awful, similar to vomit. My primary doctor doesn't know why and doesn't seem concerned, but why would I begin smelling so awful? Is something amiss?

Dr__Wilson_Tang: It is not too common for patients to have sweat that smells, at least not commonly associated with the heart failure condition or the medications used


Diagnostic Testing for Heart Failure: EKG, Ejection Fraction and MUGA

Sharma: I am a sleep tech who encountered a pt. who had HCM.Apneic events did not seem to be a factor. Are there any "tell-tale" indicators that can be picked up in a 2 lead EKG(as used in sleep study raw data) that would help identify HCM

Dr__Wilson_Tang: Usually patients may present with significant ventricular hypertrophy in 12-lead EKG, but not in rhythm strips. And EKG findings are not specific for hypertrophic cardiomyopathy.

MurielK: I have been diagnosed with Congestive heart failure. I was just recently told my EF is 20% and that if it goes down into the teens I would be a candidate for a heart transplant. Can you please tell me what I can do to either improve this EF or have it stay the same? I look forward to your answer. Muriel

Dr__Wilson_Tang: there are several questions about changes in EF as indicator as of progression or regression of disease.

Dr__Wilson_Tang: It is important to recognize that the amount of EF being injected from the heart ("ejection fraction") depends likely on the actual structural abnormality of the heart as well as the efficiency of the heart. This "number" changes with different conditions, with different measuring techniques, and by different people interpreting it. It is not a true absolute number that we can tell whether someone is getting better or worse.

Dr__Wilson_Tang: Clearly we like the EF to improve. But - the lack of changes while having improvement in symptoms and exercise tolerance are good indicators that the condition is stable.

Dr__Wilson_Tang: In fact, many of the current drugs given to delay the progression of disease and therefore patients may continue with a "low EF" for a long time.

Dr__Wilson_Tang: Also - many patients may have improvement over a longer period of time - months to years - and especially when different treatment modalities like pacemakers and new drugs emerge.

thechoop_1: Is there an objective way to measure the ejection fraction? My father's doctors disagree on the numbers.

Dr__Wilson_Tang: Cardiologists often view EF as an indicator of severity but more in a global sense than the specific numbers. The gold standard for clinical evaluation of EF is an MRI. But - it is often not necessary because it is usually an assessment to distinguish someone who has a preserved pumping function vs. an impaired pumping function of the heart.

Dr__Wilson_Tang: In fact, there are patients that have significant signs and symptoms of heart failure with preserved or borderline EF while there are minimally symptomatic patients with a low EF.

Dr__Wilson_Tang: The mechanics of the heart is beyond just the pumping part, it also involves the stretching (diastolic function); the coordination of the chambers (synchrony); and the efficiency of the valves.

johnnnita: Is a Mugga test a more accurate measure of ejection fraction?

Dr__Wilson_Tang: A MUGA test is nuclear scanning technique to measure the volume of the heart chamber. It usually is about 5% or so higher on average than what is visually estimated using an echocardiogram.

Dr__Wilson_Tang: While there is less variability in serial measurement, as previously discussed, the small changes in EF are impacted not only by technique but also by your clinical condition that may change on a daily basis.

Dr__Wilson_Tang: Clearly there are many questions no t only in this web chat but also in everyday clinic about ejection fraction. Patients need to understand that when the EF is impaired it is a category of disease and unlike a glucose level the precise changes matter far less than how patients feel functionally.

johnnnita: With regard to EF, my cardiologist recommended I have a Mugga because of different EF results from a resting echo and a stress echo. Does this make sense?

Dr__Wilson_Tang: I think it depends on why you need to know a specific EF. If it is to decide on whether you would benefit from a defibrillator than a MUGA scan, with less variability in its measurement, may be a good choice. As mentioned, echocardiographic determination of EF does vary up to 5 - 10 points depending on the person as well as the interpreter. Nevertheless, once deemed impaired, the general treatment approach remains the same, therefore serial measurements do not make significant impact on your condition


PVCs and Heart Failure

ilac34: My brother has cardiomyopathy - his EF is 38%. He gets a lot of PVCs. Is that normal? His doctor wants to him to have an ablation? will that cure it or can they come back?

Dr__Wilson_Tang: PVCs in the setting of cardiomyopathy is not entirely normal. Ablation in the setting of large PVC burden (more than 10% of total heart beats) warrants consideration for ablation. Our experience has been favorable with improvement in EF after successful ablation. If there are persistent pvcs and symptoms we have also utilized medical management but the various drugs that are used have a wide range of side effects.

CharChar: Diagnosed with CHF, viral, EF 20%. 4 mos. of meds. no change, Defib in Apr. Pericardium perforated,took 4 mos.to get back.Dr. says PVC's & tachycardia is wearing out heart. After review of hosp.record all surgeries a no go. Nothing left for me -wait to get progressively worse then maybe transplant. Walk 3 miles daily. Feel fine. I want to do something now to keep my 20% working. Suggestions?

Dr__Wilson_Tang: Although we often attribute to viruses a culprit for heart failure, your doctor's concern that pvcs or tachycardia as a cause is appropriate. We have had a large experience of ablation therapies to alleviate pvcs or underlying atrial tachycardia that results in an improvement in heart function.

Dr__Wilson_Tang: Clearly these are invasive procedures and complications like the one you recently experienced do occur so the risks and benefits need to be weighted carefully.

Dr__Wilson_Tang: The potential benefit of ablation will depend on the burden of pvcs and tachycardia. But - these are likely to have lower risk than transplantation.

CharChar: Diagnosed in Dec. Cardiomyopathy, PVC's , Tachycardia. Beta/Ace./Direutic did nothing.

Dr__Wilson_Tang: : We are recognizing that either drug therapy or radiofrequency ablation of PVCs may actually help improving cardiac dysfunction associated with frequent PVCs. It will depend on the frequency of your PVCs, and whether there are underlying contributors to their presence.

CharChar: So why is my dr. doom and gloom? meds didn't budge 20%EF.Got a spanking new DEFIB. Walking, talking not shortness of breath?

Dr__Wilson_Tang: Well - clearly doctors like their heart patients to recover but the pace of deterioration differs with different patients. The fact that you may not be too symptomatic can be related to the fact that your heart is actually compensating the abnormality or perhaps you are not aware of the symptoms you are experiencing. Either way, close follow up with your cardiologist is important. We have seen patients who have improvement in EF after long term treatment (years) when initial follow up did not see any significant changes. Continue your exercise and watch out for your salt content - keep taking your medicine.


Implantable Devices: Defibrillators (ICD), Pacemakers

rsmyth: It is time for a routine Mammogram. UGH! Last year the tech hurt the area all around my ICD? I'm concerned about the leads being displaced.

Dr__Wilson_Tang: You should talk with your electrophysiologist but note that there is a very low risk with mammogram can alter the leads.

val1mc: Are you doing any trials with subcutaneous implantable cardioverter defibrillators? What is your opinion of these components?

Dr__Wilson_Tang: Many of these studies are in the planning stages. The technology is quite promising and certainly would be a welcome addition because of the risk of the malfunction or infections.

efpat: Dr. Tang, I had class 1 chf with an ef of 25. 3 months post CRT-D implant my EF was 45. My local Dr. called me a hyperresponder. All recent EF's were by echo. I am going for a 9 month echo. This one, as all of them, are analyzed by my Dr. I am interested in second Dr do an analysis. How often have you seen great variation in EF readings from the same echo?

Dr__Wilson_Tang: Well, echo readings vary by place, person and time. The variations can be truly related to the heart or variations in interpretation. Congratulations on your response to CRT. WE recently published a large series of such responders in our own experience. Usually we believe there is a primary conduction abnormality involved and interestingly it is more common in patients who have a left bundle branch block, without underlying coronary disease and when the disease has not progressed to far where structure alterations are not severe.

rsmyth: What is the difference between an ICD and a Subcutaneous implanted cardioverter defibrillator that you spoke of earlier in this chat? Is it where the ICD is placed?

Dr__Wilson_Tang: Subcutaneous defibrillator is one that may not have lead placement. Researchers have successfully made such devices in experimental settings. Clinical trials are needed to demonstrate the safety and effectiveness. We do not have this clinically available yet.


Stem Cell Therapy

wanzy: I am to receive stem cells from my own bone marrow surgically implanted directly into my heart in October. I have had cardiomyopathy for 13 years and my EF is 15 and class III-IV /chf. They seem to have had some good results. this is a clinical trial at Emory Univ Hosp in Atlanta. The company is Aastrom. What are your thoughts on stem cell implantation and have you any knowledge of success? I realize it is brand new technology in the states, but it is keeping me away from the transplant team for now! Any comments would be welcome. Wanzy

Dr__Wilson_Tang: We are also part of the Aastrom study as well as a member of the NIH sponsored stem cell network

Dr__Wilson_Tang: Currently stem cell therapy remains at its infancy. There is more and more support that stem cells may deliver factors and hormones locally rather than what is traditionally thought of as "regeneration."

Dr__Wilson_Tang: So clearly many of the studies are ongoing and at present the results have been mixed. The challenge is to find who would benefit the most and that would depend on the specific heart problem that you have.

CharChar: What do you think re; u. of Ca. study re: turning plain cells into beating heart cells.

Dr__Wilson_Tang: We discussed previously about stem cell therapy - right now it is still in infancy and not truly translated to humans.


Exercise and Weight Training

Bob_S: I am curious about the warnings about weight training after HCM treatment noted in earlier chats. Can you be more specific? Does this mean any strenuous activity such as operating a chain saw and carrying cut-up logs, or is there something unique about working out with weights? Thanks. HCMpatient

Dr__Wilson_Tang: Resistance exercises often pose more impediments of forward flow in the heart. This may operate in a wide variety of ways.

Dr__Wilson_Tang: In patients with HCM, particularly those with thick ventricles where there is an obstructive component, such maneuvers may exacerbate the already obstructive nature of the condition and thus exacerbate their symptoms. Clearly you have to monitor your symptoms as you are doing these tasks and if there are any doubts you should ask your doctor to evaluate your exercise capacity in a formal stress test.

hocum: I have hypertrophic cardiomyopathy and would like to know how vigorous an exercise program I can participate in. I have an ICD that has never fired yet.

Dr__Wilson_Tang: Usually you can exercise as tolerated at moderate intensity - we often advise patients not to participate in competitive sports. Your exercise tolerance can be tested by a stress test where we look at both the functional capacity (how much you can exercise) and what does your heart rate and blood pressure respond to exercise. A drop in blood pressure at peak exercise indicates obstruction and should be evaluated accordingly.

Frodo: Hello Dr. Tang, I have idiopathic HF with an EF of 30 (up from 15). I'm taking coreg. Can I reverse my HF by exercise?

Dr__Wilson_Tang: There has some data to suggest that a regular exercise and intensive regimen of aerobic exercise (walking on a treadmill) is associated with better long term outcomes if you stick to it.


Stress and Heart Failure

Frodo: Dr. Tang, How does stress affect HF? Can it cause HF?

Dr__Wilson_Tang: Yes - the link between the heart and brain is mysterious. There is a specific condition called stress cardiomyopathy that we are beginning to recognize. It is also called Takotsubo or apical ballooning cardiomyopathy.

Dr__Wilson_Tang: This is an extreme form of stress induced and the underlying cause is still unknown. Other patients may have coronary spasm which could also lead to heart failure symptoms.


Genetics and Cardiomyopathy

butterflygirl: Can dilated cardiomyopathy be related to a genetic problem. I am 28 years old and was diagnosed recently with dilated cardiomyopathy. But my mom also had this condition and died in her 50s. I am concerned that mine will progress to the same. Someday I want to get married. I am dating someone now and wonder if I could have kids or what my life will be like with this condition?

Dr__Wilson_Tang: About 1 in 5 patients with unexplained cardiomyopathy have a family history of heart failure. Several genes are currently detectable with clinical testing. Various large centers provide genetic testing and counseling, including the Cleveland Clinic.


Ischemic Cardiomyopathy

sarah: I have coronary artery disease and ischemic cardiomyopathy. I have been told there is nothing that can be done for me at this time. I am 58 years old with an EF of 30%. Is transplant the only option for me? I have shortness of breath.

Dr__Wilson_Tang: I often tell my patients transplant is one of many options in advanced heart failure. Other options include mechanical assist devices, biventricular pacemakers or surgical interventions as well as careful medical therapy and lifestyle modification.

Dr__Wilson_Tang: Whether you are eligible for transplant will determine if you have a predominantly heart failure condition while other bodily functions are preserved. Also - it necessitates that you can tolerate the stress and psychosocial burden of organ transplantation.


Chemotherapy Induced Cardiomyopathy

sars03: I had cancer and adriamycin treatment. I now have cardiomyopathy. I am on water pill and a low sodium diet. I am wondering if there are special treatments for adriamycin induced cardiomyopathy?

Dr__Wilson_Tang: We treat chemo induced cardiomyopathy in a similar matter as any other courses of heart failure. There are strategies to detect underlying dysfunction before heart failure ensues but in your case it appeared that it occurred. Some patients receive herceptin as adjunctive chemo and when stopping herceptin their heart failure recovers. Adriamycin directly damages the heart muscle but in large series of patients, standard treatment still provide benefit in symptoms and improvement in EF for almost half of the patients treated.


Non-Compaction Cardiomyopathy

shirley: my niece has something called Non-Compaction Cardiomyopathy. I understand it is pretty rare and I wonder 1. do you treat this? 2. what are the treatments for this?

Dr__Wilson_Tang: Non compaction is a pathologic diagnosis of a rare condition where the apex (tip) of the heart appears to be more thick than normal. It causes heart stiffness and often has a genetic component.

Dr__Wilson_Tang: There is still a lot of controversy surrounding whether it is a unique condition or whether it is in a spectrum of a Hypertrophic cardiomyopathy.

Dr__Wilson_Tang: We usually treat it with medical therapy but in selective cases, some patients may progress with rhythm problems or heart failure and they may need more advanced management.


Supplements and Vitamins

Regina: I am a R.N. and I have Idiopathic Dilated Cardiomyopathy since 1999. No Hx of drugs/ETOH/smoking/MI/CAD. I'm doing very well and want to remain so. I just turned 65 Y/O. On Vasotec 10mg BID, Coreg 18.75 mg BID & Lasix 40mg Q AM. Received ICD in 2005 and a new upgraded model in August 2008 because of slowing of the battery recharging time. I have the Latitude remote monitoring system at home. I did have a full life-saving shock May 2008. But nothing since 2008…all is quiet (No VT's or short runs). EF is around 19%. SOB problems are with hills/inclines/steps/windy/cold weather. I rest when I get tired but then I'm good to go in about 20 minute’s time. I eat healthy....I stay away from the salt shaker and salty foods, soda, meat, junk foods, and as much preservative/hormone/additive-free food products, as possible. In other words, I try to eat clean fresh organic fruits and veggies (not processed) and fresh wild caught salmon, halibut etc., whole grains and beans. Any thoughts/ideas/suggestions for me? Any Vitamin &/or Mineral/Herbal supplements you can suggest? I have three very young grandsons and I want to see them grow up. Thanks so much!!!

Dr__Wilson_Tang: At present, the majority of the herbal and natural supplements do not have proven benefits that have been demonstrated in large clinical trials. The only exception is fish oil that has been tested in an Italian study that found a small but statistically significant improvement in long term outcomes.

Dr__Wilson_Tang: The biggest thing that you can do to improve your current status is to start a regular exercise regimen.

terrymii: what do you think about the treatment of coq10 in use with heart failure?

Dr__Wilson_Tang: Several small studies have examined coQ10 but the results are inconclusive. It is commonly used in pediatric cardiomyopathy for conditions related to mitochondrial dysfunction, but these are rare genetic conditions. Currently we do not routinely prescribe coQ10 to patients.

Cleveland_Clinic_Host: I'm sorry to say that our time with W.H. Wilson Tang MD, is now over. Thank you again Dr. Tang for taking the time to answer our questions about Heart Failure and Cardiomyopathy.

rsmyth: Thank you so much for having this chat, Dr. Tang. It was very informative and I appreciate it:)

CharChar: Again, you are more positive and give more support that what I've grown accustomed to. Thank you!

Frodo: Yes, Thank you for your wisdom!

johnnnita: thank you for the webchat, Dr. Tang. It's most helpful and educational.

thechoop_1: Please pass along my thanks to Dr. Tang for sharing his expertise.

Dr__Wilson_Tang: You are welcome. Thank you for having me today.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 08/10


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