Heart Failure (Drs Starling&Navas 1 26 12)
Thursday, January 26, 2012 - Noon
Congestive Heart Failure is a chronic, long-term disease that can be managed through medication, life style changes, and in some cases surgery. Nearly five million Americans are affected by heart failure and it is the number one reason for hospitalization for Americans over the age of 65. Dr. Navas and Dr. Starling answer your questions about heart failure.
Heart Failure General Questions
Dave_s: I am a 78 year old man whose ejection fraction dropped from 45-50 percent to 25-30 percent after a leaky aortic valve replacement over 3 months ago, after which I developed Congestive Heart Failure symptoms. Subsequently, I’ve been taking Coreg (3.125 MG twice daily) , Lisinopril, Lasix, Lipitor and Digoxin, They are not raising the Coreg dosage because my blood pressure and heart rate sometimes drops too low. The next echocardiogram is six months away. What are my chances of improving the ejection fraction with that minimum dosage of Coreg? Also, should I restrict my physical activity or try to increase it? I walk about 45 minutes per day. What should be the minimum and maximum daily fluid intake?
Dr__Navas: The chances of EF improving if nothing else has occurred regarding your heart, the fact that you changed your valve, there is a good chance for improvement in EF with your echo in 6 months. Usually patients with Aortic Regurgitation (leaky heart valve) usually the EF improves when the valve has been replaced.
- The ideal dose of coreg for heart failure patients is higher than that but if you don't tolerate a higher dose, the fact that you are on at least that dose - it is still helping.
- The amount of exercise you are doing daily is ideal. That is the right amount - do not decrease it.
- Don't drink less than one liter a day - maximum - I would keep it less than 2 liters a day.
KatD32: My sister who is 29 was just diagnosed with a weak heart. I am not sure what that means. She has 2 children and her doctor is meeting with her tomorrow to go over her treatment. What can she expect?
Dr__Starling: This is an important and complex question. Your sister will obtain information hopefully about the cause and the prognosis for her weak heart. She may require additional testing to pinpoint a specific cause. Approx. 20% of patients with weak heart muscles have a familial condition. Many patients after a thorough evaluation will not have a specific cause identified for the weak heart muscle. Sometimes genetic testing will be indicated and helpful depending on the specific type of weak heart muscle or cardiomyopathy. You can expect that her children and other family members may be advised to undergo testing to see if they have any evidence for or susceptibility for developing a weak heart.
The good news is that many causes of weak heart muscle disease today can be treated very successfully. I would emphasize that a patient with a weak heart muscle should be evaluated by a cardiologist or heart failure specialist.
Jonesy: What is the difference between diastolic dysfunction and heart failure?
Dr__Navas: Diastolic dysfunction is a stiff heart with a normal systolic function or ejection fraction. There are different degrees of diastolic dysfunction. Most people develop mild degrees with age. Having diastolic dysfunction does not mean you have diastolic heart failure.
MeBTrue: My mom has heart failure. She is 72 years old. I saw an advertisement for a heart failure management program but not sure what the difference between that and seeing her cardiologist would be. Her visits to her doctor have been more lately so I am wondering if a management program would help her.
Dr__Starling: A heart failure disease management program includes nurse practitioners, dietitians, and heart failure specialty cardiologists that focus the care of the heart failure patient intensively to optimize their care to provide immediate access for treatment with changes in weight or increased symptoms and close monitoring of daily weights and vital signs.
The goal of heart failure disease management programs is to provide frequent visits and care to reduce the need for hospitalization. Research trials have also shown that in addition to reducing hospitalizations heart failure disease management programs may also reduce the mortality rate as well.
CLSTAR: What causes a "stiff heart muscle"?
Dr__Starling: A stiff heart muscle may be assoc with common conditions such as high blood pressure that can cause thickening and stiffening of the heart muscle. There are also conditions that lead to infiltrative cardiomyopathy. Examples include protein, iron, or other substances that get into muscle cells or between them in the heart. Heart failure with preserved ejection fraction is associated with "stiffening of the heart" and there may not be as specific cause identified.
CLSTAR: when a heat failure person starts retaining fluid in the abdomen, liver and spleen can anything be done to help?
Dr__Navas: Trying to get rid of the fluid accumulated can be done by different means such as increasing the dose of diuretics and if it is not responding to higher doses of diuretics, a procedure called paracentesis would be performed to drain this fluid. I would recommend you consult your heart failure specialist.
Diagnostic Tests for Heart Failure
Charles: Can you talk about the bnp test? When do they use the bnp test? how often should you get it retested? what do the results mean?
Dr__Starling: BNP test refers to brain natriuretic peptide. BNP can be used to assist in the diagnosis of heart failure. It is typically measured in the emergency room when patients come with shortness of breath and swelling. An elevated BNP would certainly warrant further evaluation to precisely diagnose heart failure and the potential causes.
Serial measurements of BNP to guide in the treatment of patients with heart failure are currently being assessed in ongoing clinical trials. Early data suggests BNP measurements may be helpful over time to help optimally manage heart failure patients.
In general, an increase in BNP is associated with fluid retention and a decrease is associated with improvement in the patient's overall congestion. So - high is bad and low is better.
ScottCL: What is the best test to look at ejection fraction? The echo or the MUGA scan? Or is there something else
Dr__Navas: The most common and widely used method to measure EF is the echocardiogram because it is readily available and easy to perform. The MUGA scan became the preferred method to measure EF in the 70's especially because it is very reproducible and you get very accurate numbers. It is not used as frequently any more because it has some disadvantages including some radiation to the patient and the fact that we cannot really see other structures of the heart, like the valves.
Currently - the most commonly used method is the echo but if we need more accurate numbers to make clinical decisions cardiac MRI is becoming the preferred modality to measure EF.
Medications and Heart Failure
tennbarb: This might not be of general interest BUT what is the evidence on use of losartan for reduction of left ventricular hypertrophy? Is it effective and at what dose? Any agent better than losartan for this purpose.
Dr__Navas: Losartan is one of the groups of medications used in the treatment of heart failure. Its use in the treatment of LVH is limited but some of these meds have shown to improve diastolic heart failure, which could be a result of LVH. It is part of the antihypertensive meds - so it would help to prevent additional LVH caused by hypertension. The dose can be individualized to the patient.
Jeanne_DS: Can a beta blocker promote CHF because of its property of slowing down heart rate?
Dr__Starling: Beta blocker is the most important drug we use to treat heart failure. Beta blockers should be initiated with caution usually by a heart failure specialist. The use of a beta blocker in the wrong patient at the wrong time could cause problems.
Heart Failure and Supplements
FOrGo: I just started taking CoQ10 because my friend told me that it is good for heart strength. Will it help my heart failure/
Dr__Starling: The heart failure guidelines do not specifically recommend the use of CoQ10 for the treatment of heart failure. There are no definitive clinical trials that have shown this therapy to be effective. There are some very specific forms of cardiomyopathy assoc with abnormalities of metabolism where CoQ10 may be prescribed.
Heart Failure and Pacemaker Therapy
Sam_K: I know someone who has heart failure and they got a pacemaker to help their heart pump better. My dad now has heart failure and the doctor has not mentioned that. Are there certain criteria as to when this would work and when it would not - or should I ask about this?
Dr__Starling: Pacemakers play an extremely important role in treating patients with heart failure.
There are very specific criteria that determine eligibility and predict the potential for improvement with a pacemaker. Pacemaker therapy is referred to as cardiac resynchronization therapy. Generally, patients that are eligible have a bundle branch block which is a marker for response to treatment with a pacemaker. A heart failure specialist that reviews your case can advise you on your eligibility for pacemaker therapy.
witter123: When is it time to replace my Medtronics ADDR01 pacer with a biventricular device?
Dr__Starling: It depends on many factors and is best answered by an electrophysiologist or heart failure specialist. Certainly if your condition has worsened and you have more symptoms we would encourage you to seek consultation with your cardiologist now.
Heart Failure and Diet
Kitty_L: Is there any nutritional link associated with CHF? Will fish oil capsules help?
Dr__Navas: There are some nutritional deficiencies that can cause heart failure. But - in a well balanced diet, they are extremely uncommon. Fish oil is useful in maintaining a good lipid profile and decreasing the risk of coronary artery disease from high cholesterol.
Dr__Starling: Some clinical trials have given hope that fish oil may play a positive role however, more definitive clinical trials are required.
gert: I saw something on line that many people are not even salt sensitive - so how important is a salt restricted diet if you have heart failure.
Dr__Navas: Salt restriction is extremely important in heart failure. It is one of the most important recommendations we give to patients with heart failure to help with their medical management. Salt restriction helps to prevent high blood pressure and helps to prevent fluid retention. For heart failure patients the recommended amount is between 1500 mg up to 2 grams a day of sodium.
FrankR: Hi. My dad has heart failure but he continues to have a drink, or two every day. How important is it to restrict alcohol when you have heart failure.
Dr__Starling: Alcohol can be a cause of heart failure and can certainly contribute to worsening of the condition. Alcohol should be completely avoided and I encourage you to discuss the use of limited alcohol for your father with a heart failure specialist. Some patients are permitted to consume limited amounts of alcohol with heart failure.
Heart Failure and Exercise
MargieF: They said to exercise and I am a regular walker - I walk every day. Is it ok to walk outside when it is cold?
Dr__Navas: It is great that you walk every day. I do not see a problem with you walking outside in the cold.
Kim: My son is 24 years old and had a virus and now has cardiomyopathy. He is actually doing pretty good right now - he is taking medications and continues to work out - he runs at a slow pace but for about 30 minutes or 40 minutes on a treadmill but he also has been lifting weights and I am concerned that this will damage his heart. Are there any restrictions regarding exercise when you have cardiomyopathy?
Dr__Navas: Repetitive lifting of more than just a few pounds should be avoided in patients with heart failure. This could cause deleterious affects with ventricular size and function. Aerobic exercise of 30 - 40 minutes on at least 3 days of the week is very reasonable.
Coronary Artery Disease, Heart Attack and Heart Failure
Marjory: My husband had a heart attack last week. While in intensive care, they told us his ejection fraction was 30% but it can improve with his recovery. Can you tell me how long after a heart attack to they evaluate for your heart function damage to see what is going on.
Dr__Starling: Usually ejection fraction is re-measured at least 40 days after a heart attack and then every 3 - 6 months until the EF stabilizes. The EF can improve especially if a stent or bypass is performed and prevented permanent heart muscle damage.
Clara: I have 2 bypasses and 6 stents since the bypass surgery. I read that coronary artery disease is one of the main causes for heart failure. Could you explain why? Also, is retaining fluid in the stomach a sign that one could be developing heart failure?
Dr__Starling: Coronary artery disease is one of the main causes of heart failure because it can lead to heart muscle damage and weakening of the heart muscle and subsequently heart failure. It is important that appropriate medical therapy and treatment for coronary artery disease is optimal. Retaining fluid in the stomach could be a sign of heart failure. It is best to see your doctor or heart failure specialist for a thorough evaluation.
Atrial Fibrillation and Heart Failure
leo542: I have had atrial fibrillation for some time. I am on medication to control it. Lately I have had more shortness of breath. Can atrial fibrillation turn into heart failure?
Dr__Navas: Atrial fibrillation by itself can cause symptoms of shortness of breath. Long term atrial fibrillation especially when it is not well-rate-controlled can eventually cause tachycardia induced cardiomyopathy.
Dr__Starling: Atrial fibrillation is one of the important potential causes of heart failure that is fully or partially reversible.
Char22: Hi. My husband has atrial fibrillation and high blood pressure. He also sometimes has swelling of his feet so his doctor has him on sotolol for his afib, metoprolol for his bp and lasix for his swelling. I wonder if he has heart failure and if he should be on other medications. Isn't swelling a sign of heart failure? How do you know?
Dr__Navas: Atrial fibrillation and high blood pressure does not mean he has heart failure. It would be helpful to review his echocardiogram to see what his diastolic and systolic function is. Also - having low extremity edema is not always caused by heart failure. It could be caused by venous insufficiency. But if he does have heart failure he should be on other medications. You can discuss your concerns with his doctor and I would recommend an echocardiogram. We would be happy to see him.
Diabetes and Heart Failure
JG876JG: My dad has had diabetes for many years - he watches his diet and takes medication. He was just diagnosed with heart failure - are the two related?
Dr__Navas: Diabetes increases the risk for having heart failure - Independent of having coronary artery disease or hypertension. Yes - they can be related. If he has a new diagnosis of heart failure other causes such as coronary artery disease and high blood pressure need to be ruled out first.
Heart Failure and Sarcoid
LoewsMark: I have a friend that has sarcoidosis and now has pretty bad heart failure, would that limit his treatment options? does that change the way they treat the heart failure?
Dr__Starling: If your friend has sarcoidosis and heart failure it is very important to determine if the cause of heart failure is from cardiac sarcoidosis. This requires specialized testing which may include a heart biopsy. If there is evidence of active inflammation in the heart from sarcoid, your friend may be eligible for treatment that could have a very positive impact on reducing the heart failure. Cleveland Clinic has one of the largest sarcoid clinics in the nation and extensive experience in treating patients with sarcoidosis. I think it is very important for your friend to see a cardiologist with experience in treating cardiac sarcoid to determine the options.
Heart Failure Research
Messa: Can you talk about upcoming studies for stem cell therapy and heart failure. I would like to get into a study when there is one available.
Dr__Starling: At the present time, we have no studies at the Cleveland Clinic open for enrollment. We anticipate in the next few months a stem cell trial that is multi-center sponsored by the NIH to begin for patients who are undergoing left ventricular assist device implant for severe heart failure.
Dr__Navas: There are always trials going on with new medications for heart failure but the ones we have available in the US have been around for some years now. The list includes beta blockers, ace inhibitors, aldosterone blockers, hydralazine in combination with isordil. These remain the main medications available for treatment of heart failure.
Dr__Starling: INNOVATE HF is a global study including the US for patients with heart failure where a device is implanted to stimulate the central nervous system with a pacemaker like device which is a novel new form of treatment being tested.
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