Heart Failure (Dr W H Wilson Tang 12 1 11)
Thursday, December 1, 2011 - 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. Tang answers your questions about Heart Failure.
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.
Cleveland_Clinic_Host: Welcome to our "Heart Failure" online health chat with W. H. Wilson Tang, MD. We are sorry to say that Nicholas G. Smedira, MD is in surgery and will not be able to join this chat.
Diastolic and Systolic Heart Failure
bhakta: 1. In completely asymptomatic geriatric patient population, how would you treat moderate diastolic heart failures with accompanying moderate PH? Would you do something over and above OMT (optimal medical therapy: keeping BP around 130—140; use of all four BP drugs: diuretics, CCBs, ARBs, aldosterone antagonists)? 2. To remove the PH confusion (PAH vs. PVH), if their right-heart cath shows that PH is only due to LH disease, then would you still like to give any nitrates or sildenafil?3. What about Late Sodium Current Inhibitors such as Renalozine?4. Any role of EECP?5. Finally, there are early indications that L-arginine may help the diastolic dysfunction by modulation of Arginine-NO pathway. Since L-arginine is just an amino-acid, does L-arginine supplementation provide any harm? Could it help?Some of these questions are tricky for us since at 85+ geriatric population, we do not have enough studies.
Dr__Tang: The current guidelines recommend strict blood pressure control as you have mentioned regardless of what drugs are chosen. Ongoing studies are currently conducted to determine if drugs like sildenafil or ranolazine can help, but neither drugs have enough data to warrant their clinical use. There have been a lot of hype about nitric oxide donors such as nebivolol, L-arginine, and EECP, but none of them have consistently demonstrated beneficial effects that are directly related to enhanced nitric oxide production. L-arginine has show to have more adverse events in the post-infarction population, but has not been well studied in the diastolic heart failure population. However, it is important to ensure that arrhythmia and congestion are detected and treated accordingly.
Saumil: Dear Doctors, We appreciate this opportunity to ask some questions about DLHD (Diastolic left heart disease) - especially *advanced pseudo-normal* for non-symptomatic cases. 1. Is there any benefit of Late I(Na) inhibitors in diastolic dysfunction? 2. What are novel bio-markers in diagnosis of diastolic heart failures - especially its progression (over and above Nt-ProBNP, 3D echo etc.). 3. In DLHD, what are the new treatment options that are being researched? Pharmacological and non-pharmacological? Thanks. - Saumil
Dr__Tang: Ranolazine (late Na current inhibitor) is currently used to treat angina and in animal models has some mechanistic data to support potential improvements in diastolic function. However there are very few human data and several small mechanistic human studies are underway.
Currently there are no specific biomarkers that can define diastolic heart failure (also know as heart failure with preserved systolic function). this is likely because there are multiple courses leading to this presentation. BNP and Nt-ProBNP allows the detection of underlying myocardial stress and is elevated in this patient population and is incorporated as one of several criteria in some guidelines.
In diastolic heart failure there are several major clinical trials looking at drugs used for systolic heart failure in the diastolic heart failure population. So far none have demonstrated incremental benefits in the population as a whole. It appears that diastolic function improves with aggressive BP control regardless of medication class. The current guidelines still recommend aggressive BP control, relieving congestion and managing heart rhythm as the three major targets of therapy. There are ongoing developments of novel drugs targeting specific cellular mechanisms in these patients but they are still under investigation.
The major advance over the last years has been the publication of the CHAMPION study using a pulmonary artery pressure monitor that is implanted in patients with advanced HF, a subset with advanced diastolic HF and the results demonstrated reduction in adverse heart failure events.
charlotte: what is the difference between systolic and diastolic heart failure?
Dr__Tang: Systolic heart failure means impaired cardiac function that is measureable in cardiac imaging.
Diastolic heart failure usually has preserved contractile (pumping) function but impaired filling of the ventricle.
caroline88: I recently had an abnormal stress echo and then a cath. The doctor said I have diastolic heart failure caused by high blood pressure that was not treated. Is that the only cause of diastolic dysfunction. I have never had high blood pressure in the past.
Dr__Tang: No - there are many potential causes with high blood pressure being one of them. Further evaluation of other causes would be advised. Some causes are related to abnormalities in the heart muscle itself and some are related to systemic diseases such as diabetes and other problems.
toral: How is diastolic dysfunction treated in the geriatric population? Are there any new treatments that could prevent progression of this condition?
Dr__Tang: Aggressive BP control, relief of congestion and rhythm control are the mainstays for all patients. There is an age appropriate diminishment of diastolic function, hence, lifestyle modification and exercise are important to maintain adequate diastolic function.
toral: how is the diastolic dysfunction treated in the geriatric population? Our father is 86 years of age and he has had episodes of ectopic beats and no cardiologist seem to know what is going on. He recently had an angiogram done and it came back normal but his BP keeps fluctuatiing, at times from very high to low, what do you recommend we do? Our father had a kidney transplant in 2000 and is diabetic and had RCC in 2007.
Dr__Tang: Patients with diabetes and kidney disease have significant heart stiffening that would benefit from aggressive blood pressure and glucose control
marilynm: Can you explain "stage 1 diastolic dysfunction"? I'm 56 and my bp is 120/80. Is this liable to get worse?
Dr__Tang: Stage 1 diastolic dysfunction is when there are fluctuations in flow that is detected in the echocardiogram. Sometimes it could represent an age related change and sometime it could be related to underlying heart muscle conditions - or changes in loading conditions. Our extensive database at the Cleveland clinic has shown that in patients with stage 1 diastolic dysfunction , their long term outcome is equivalent to those without when adjusted for clinical variables. Continue with your healthy lifestyle.
Symptoms of Heart Failure
barnyrubble: what are the warning signs of heart failure. High blood pressure? high resting heart rate? weak and tired easily?
Dr__Tang: Signs and symptoms of HF include shortness of breath, fatigue, exercise intolerance and congestion (edema of legs, abdominal swelling). Sometimes nonspecific signs such as fullness and night time coughing can also be related. Risk factors include DM, BP and other common risks for heart disease. A strong family history of heart failure or heart disease are not uncommon in patients who develop HF.
Blood Pressure and Heart Failure
johnnnita: what is the relationship between low blood pressure/pulse and heart failure? Is there direct relationship? If not, what should a person be aware of when living with low blood pressure? For example, I exercise regularly for 45 minutes every day with no problems or symptoms.
Dr__Tang: If you have a diagnosis of heart failure it is beneficial to maintain a low heart rate and blood pressure provided you can maintain every day activities and exercise. Drugs like beta blockers lower heart rate and has perceived as an important effect that is linked to the benefits. This has been confirmed in Europe where a drug that specifically slows the heart rate is associated with beneficial outcomes (that drug is not available in the US).
In patients with hypertension, lowering of blood pressure will lower the resistance of the heart to pump forward. However, too low of a blood pressure may reduce perfusion of major organs and cause trouble. Therefore the optimal BP differs among individuals and usually ranges from 90 - 100 systolic range.
tirreno: What is the ideal blood pressure for someone with heart disease? I am 54 had triple by pass 12 years ago, and two stents two years ago. I am on metaprolol and benicar for blood pressure. I recently backed off on metaprolol from 50mg a day to 25 mg because my heart beat per minute was averaging 52. Over the last couple of months with only 25 mg my heart beat per minute is averaging 70 and I feel much better. My blood pressure is averaging 125/60. Should I be concerned about the 70bpm and the low 60's in the systolic??
Dr__Tang: You seem to be doing well. It is advised to have a BP of less than 130/80 in patients with some risk factors.
Cleveland_Clinic_Host: Thank you for joining us, let's begin with the questions
NPA: I have a series of questions: #1 - My husband has been told he may soon be referred for transplantation evaluation. What is the evaluation process at the Cleveland Clinic and do you accept patients that are approx 6 hours distance for a transplantation?
Dr__Tang: All patients are welcome for evaluation for proper therapy for advanced heart failure. Transplant is one of several options that are currently available for patients with advanced heart failure. We have many patients that live a distance away however there are specific requirements for eligibility.
NPA: Question #4: What should we look for when comparing heart failure clinics for transplantation or other alternatives? We have been given a choice of looking at Univ of Mich, Northwestern U, and Cle. Clinic? What should we use in our evaluation process for finding optimal care and balancing distance of travel?
Dr__Tang: All outcomes data for heart transplant is available publicly at http://www.ustransplant.org. This includes the volume, waiting list times, short and long term outcomes reported at each institution.
Ventricular Assist Device (VAD)
jonathan_LA: I was reading up on VADs for my sister who has bad heart failure. There are different types. How do they match the type of VAD to the patient? when do they know a patient should go on a VAD device?
Dr__Tang: evaluation for candidacy for VAD is similar to a transplant evaluation where exclusion of significant additional medical conditions and the ability to improve quality and quantity of life is potentially achievable with the device. Most people receive continuous flow VADs because of their small size and improved outcomes over years of improvement. Investigations into smaller VADs and implantation in less advanced patients are ongoing.
leon: For Dr. Smedira. I have not heard much on progress on mechanical heart replacement pumps for long term use. Is there new technology for this as an alternative to heart transplant.
Dr__Tang: I will answer for Dr. Smedira. The newer version of continuous pump utilizes centrifugal technology and is smaller than the standard heartmate 2 VAD. Clinical trials have demonstrated its safety with much smaller surgical pocket, ongoing studies on both bridge to transplant and destination therapy are ongoing. There have been anecdotal clinical evidence world wide on putting these smaller pumps in both ventricles but not commonly performed. Several studies are in the planning phase to investigate the use of newer continuous VADs in patients with less advanced heart failure because their long term durability has improved over time.
Francois: Can the echocardiographic values of mitral E/A ratio and the Deceleration Time of early filling velocity, DT show false decreases in a person suffering from significant anxiety and stress and labile hypertension? Can the Relative Wall Thickness, RWT show a false increase, leading to wrong indication that mild diastolic LV dysfunction and concentric LV remodeling are present? I and a 73 year old healthy male and my E/A is 0.7 and my DT is 161 and RWT> 0.45 with normal LV mass and normal left atrial cavity size. The Heart Rate was 87/min though normally it is much lower.
Dr__Tang: Echocardiographic values of diastolic function are highly variable and depends on the loading condition of the heart (that is how much blood volume coming in and out of the heart) as well as different conditions (at rest, during exertion). There is also marked variability in the acquisition, and many of such parameters are calculated or estimated. If there are no obvious structural abnormality and otherwise healthy, it is possible that much of these could be age-appropriate and may not affect long-term clinical outcomes. That is why echo results need interpretation in the clinical context and not just comparison of the measurements to normal values.
Brent: One more question - what additional tests or measurements should I know. Or possibly look to be done to aide in my decision. My doctor is knowledgeable but I for the most part feel great. I am Overwhelmed by the thought of the ICD, the related costs and its mental effects. I need more because I’ve read articles that question the validity of the ICD in my kind of situation
Dr__Tang: The ability for us to adequately predict SCD makes ICD a very powerful tool to advert unanticipated events. IF there are questions related to the severity of cardiac dysfunction, we sometimes perform an MRI which is the most accurate measurement of cardiac function. But EF is one of many criteria that goes into this decision.
Rose123: Does a noncompacted ratio of 2:6 from a cardiac mri definitely mean a non-compaction cardiomyopathy diagnosis? Ejection fraction 67 left and 56 on right. Right side of heart well over twice the size of left.
Dr__Tang: The ratio detected by MRI is one of several criteria used to diagnose noncompaction. There are other possible cardiomyopathies in which the right side is larger than the left.
bhakta: Would trying Pulmonary artery monitor be something we should consider In an 87 year old with advanced pseudo-normal, BP 130-145, asymptomatic, moderate PH due to left heart disease(PAP 64, 24, 36)? Are there any potential negatives that we should be aware of? We really really want to be proactive!
Dr__Tang: PA monitor is an invasive procedure and it is still awaiting FDA approval . There are patients who may not necessarily benefit including those who have poor kidney function and poor life expectancy of cardiac conditions. Individual evaluation is needed.
Rose123: One more: is a non-compacted ratio of 2:6 significant versus normal trabaculations?
Dr__Tang: Trabaculations are more consistent with non-compaction but it is also seen in other inherited cardiomyopathies. These criteria evolve over time and in fact there are controversies regarding noncompaction being a spectrum of HCM vs. a specific type of cardiomyopathy.
BobK: I had a heart attack 15 years ago and I have done pretty good since then - active, play golf, walk. After the heart attack my EF was 52%. I have not had any chest pain. This past year I have slowed down a little bit and had a recent stress echo and my stress test did not show any ischemia but my EF dropped to 38%. What do you think about this? Should I have another cath? Do you think this change is due to more heart disease even though the stress test showed no ischemic EKG changes?
Dr__Tang: Changes in EF may occur after an MI although without any knowledge of any interim testing it is difficult to know whether a new cath is necessary - your cardiologist will evaluate your functional status and the appearance of the stress echo data to determine whether an ongoing ischemia is suspected.
Terri: My sister had diabetes. She recently went to the hospital with heart failure. Her heart is enlarged and her EF is 30%. Can this be reversed?
Dr__Tang: Aggressive medical therapy can improve patients with low EF in a subset of population. Furthermore, patients with diabetes have risk for coronary artery disease which can be improved following revascularization.
Ischemic Heart Disease
NPA: #2 - My husband has severe Left ventricular systolic dysfunction, his previous grafts from a bi-pass are totally occluded, and he has chronic occlusion of the right coronary distribution fed via left to right collaterals. His EF is between 20-25 at this time. He had his 1st heart attack at age 28, 2nd at 31, bi-pass at 31, several stents with complications. He is now 51. Are their other options available other than transplantation in server cases? (knowing you do not know his case)
Dr__Tang: The question is whether there is still viable heart muscle that would benefit from consideration for redo bypass. That would depend on the availability of targets as well. We would need specific testing to evaluate that such as coronary angiogram and advanced imaging. In those that do not have appropriate targets and with progressive heart failure refractory to medical therapy - mechanical assist devices are a potential option.
Stem Cell Research
NPA: Question #3: What is the status of Stem Cell research for heart failure patents (such as my husbands described above)? And if trials are available, what is the process for qualification?
Dr__Tang: While there are some promising ongoing research suggesting potential benefits of stem cell therapy in heart failure, clinical trials are going to examine the clinical efficacy of this therapy. Several industry sponsored studies as well as studies conducted by the stem cell network in the United States are currently ongoing. Go to www.clinicaltrials.gov to see if there is a site.
Charles: How do the stem cells know when to stop enlarging/growing the heart when they are injected?
Dr__Tang: There are stem cells of various kinds within the heart as well as circulating in the body. We currently do not know exactly what stem cells do or how they interact with the failing heart. We do know that the majority of the injected cells do not settle down in the damaged heart and grow new heart muscle cells, but rather produce favorable hormones or factors that helps various processes within the heart or elsewhere. While studies have been promising as well as conflicting, it is still investigational and there is no consensus regarding when, what kind, and how stem cells are best delivered to help patients with heart failure.
Device Therapy and Heart Failure – ICD and Pacemaker
Brent: I am male 53 and had MI in the lad in 2005 It has been suggested I consider an ICD... having been diagnosed with an EF of 30 to 35% This has been suggested before and second test revealed no need. my question: Are there different manors in calculating EF It seems when the test "echo" is done at my cardiologists facility it comes back lower than other places... or am I just full of hope I have read a couple studies that seem to discredit the benefit of ICD compared to Quality of life in my EF range My Doctor indicated 10% possibility of SCA and I am becoming overwhelmed... Living near Dayton OH and minimal means I don't foresee a visit to Cleveland Just looking for searching thank you in advance
Dr__Tang: Current recommendation based on available clinical trial data suggests any patients with an ejection fraction less than 30% post MI regardless of symptoms or patients with EF of less than 35% with signs and symptoms of heart failure should be considered for ICD implantation. Measurements of EF do vary depend on the technique being used. There is also an inter-observer variation of up to 5 to 10 % across studies.
Consideration for ICD should account for the potential risk profile of the patient as well as lifestyle preferences in addition to the perceived benefits of ICD to prevent sudden cardiac death. Discussion with an electrophysiologist would be helpful as you make your decision. It is also clear that medical therapy does modulate EF and this is not a static measurement.
feat: Dr. Tang, Thank you for answering our questions. I am two years post CRT-D implant. Prior to implant my EF was 25 and the size of my LV was above normal ranges. My EF has been over 50 and my heart has completely reversed remodeled. I am very lucky. I would love to get off my meds (carvedilol, Atacand and spiranoltactione). Have you ever succeeded in taking a patient off meds who experienced reverse remodeling?
Dr__Tang: This is a common question although heart failure specialists would argue against taking you off any meds. We do not have any experience specifically with post CRT recovery in terms of the necessity for indefinite medications. Anecdotal evidence have taught us that stopping heart failure meds are associated with return of condition.
Aneurysm and Heart Failure
LCB48: If a person has heart failure and only a 10% ejection fraction with a 5.3 aneurysm and is told surgery isn't an option due to a very weakened heart, what is the long term prognosis? Can an aneurysm be slowed down with medication? How is it decided whether a person is a candidate for a heart transplant?
Dr__Smedira: Beta blockers and good blood pressure control are thought to be useful in retarding aneurysm growth. Smoking also is a risk factor and should be stopped.
Arrhythmia and Heart Failure
barnyrubble: can an arrhythmia cause heart failure?
Dr__Tang: Yes. There are many forms of arrhythmia that can cause heart failure; the most common being atrial fib, particularly in the setting of fast heart rate. There are some patients in which very frequent premature beats also lead to inefficient filling of the ventricles and indirectly cause progressive cardiac dysfunction.
barnyrubble: I have been suffering from some pretty severe PVC's for the last year. I have been hospitalized 3 or 4 times with multiple stress tests, EKG's and ultrasounds. Everything is supposed to be ok. My heart stops for 4-5 seconds and restarts. My blood pressure sometimes goes to 180-110 and bpm of 110 right after it starts back up. Is this normal ? Is there something else they might be missing that needs to be addressed? Thank You
Dr__Tang: Your heart stopping for 4 -5 seconds is not normal. Consideration for pacemaker should be performed if you are having symptoms. Consult an EP doctor for additional testing. The blood pressure after a PVC usually is higher as there are to be variations.
Chemotherapy and Heart Failure
Africawatcher: What is the current standard of care for second line chemotherapy where the patient has a history of resolved idiopathic cardiomyopathy and the preferred drug is cardiotoxic (anthracycline). Is cardiac function potentially compromised in favor of chemotherapy? Are other drugs used instead?
Dr__Tang: Patients who had prior cardiomyopathy are certainly at risk of developing cardiac dysfunction related to this chemotherapy drug. The general advice is to balance the benefits of chemotherapy with the aggressive treatment of heart failure medications and frequent monitoring of cardiac function to adjust the dosing.
Hypertrophic Cardiomyopathy (HCM)
Rob_M: I had a myectomy performed by Dr. Smedira on November 4, 2008. I consider the operation a complete success. Thank you, Dr. Smedira. My question: Is there anything that my local doctor should be looking for, in the future? I am now 57 years old and wanting to plan for an future medical problems that might appear because of my HCM and myectomy.
Dr__Tang: Generally we recommend ongoing risk factor modification including exercise and healthy diet to reduce cardiovascular risk. The obstruction has been relieved although a subset of patients may have a slight increase in rhythm abnormalities that should be monitored and appropriately treated.
Another new development in the area of HCM is the availability of genetic testing (70% is inherited through several genes) and potentially identify people in your family that should be followed. Ongoing studies are underway to better understand how to manage carriers of this gene mutation before overt disease develops.
HCMGuy44: I'm 67 with HCM, Afib and a leaking mitral valve. My cardiologist is pushing me to get the mitral valve worked on either by a fix or replacement...."while there is still time." He is calling it the window of opportunity hat a fix will do some good. In the condition I'm in now, what do I have to look forward to? Will my main organs start to go....will I get weaker overall? I guess I'm trying to find out if the mitral fix will accomplish anything?? Will the end result come as I just die with my heart stopping altogether. He says the Mitral valve "fix" won't really do anything for the HCM or the A Fib. My question is then Why should I bother going thru OHS if it's not going to help anything. Could you offer your opinion on this scenario. Thank You.
Dr__Tang: We have learned over the years that in HCM, there are not only abnormalities in the hypertrophied septum but also abnormalities in the mitral valve and papillary muscle. The fact that you have afib and mitral regurg suggest that your heart is currently inefficient and it may progress with further deterioration which leads to worsening symptoms.
Since this is a predominantly structural abnormality - surgery is the main treatment for this and specialized centers are very successful in treating HCM. The HCMA is a great resource for you to research centers.
melissan: I was diagnosed with postpartum cardiomyopathy after the birth of my son in August. (1) What is the typical recovery time? and (2) Is further pregnancy not recommended?
Dr__Tang: Postpartum cardiomyopathy is treated in the same manner as any other heart dysfunction including ace inhibitors and beta blockers. Some patients do recover up to 6 - 12 months time. In general - repeat pregnancy is strongly advised against because of high maternal mortality with the development of subsequent cardiac dysfunction with repeat pregnancy.
Mitral Valve Surgery
fixedvalve: Hello, I am 37 days post-op mitral valve repair from the Cleveland clinic, before I had the surgery my resting heart rate was 53 bpm, now it is around 84 bpm. My question is will it drop again as my activity increases or did the surgery cause it ? I am only on a cholesterol med and Advil now for the pain. I am an avid mountain biker and kayaker. So you can see my concern. Thank you
Dr__Tang: I would recommend enrollment in a cardiac rehab program and continue to monitor your heart rate through recovery.
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