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Heart Failure & Cardiac Rehabilitation (Drs Navas Starling & Wolinsky 1 24 13)

Thursday, January 24, 2013 - Noon


Heart failure is a chronic long term disease that can be managed through medication therapy, lifestyle changes, and surgical intervention and commonly with cardiac rehabilitation. Nearly five million Americans are affected by heart failure and it is the number one reason for hospitalization for American over the age of 65. At Cleveland Clinic our expert cardiologists and cardiac rehabilitation teams are dedicated to diagnosing, treating and managing heart failure. Dr. Navas and Dr. Wolinsky, Cleveland Clinic Florida, and Dr. Starling, Cleveland Clinic Ohio campus, answers your questions.

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Highpointer42: Can congestive heart failure be present without signs of fluid retention?

Dr__Starling: Yes. Fatigue and shortness of breath are common symptoms with or without swelling of the ankles or other common signs of fluid retention.


Howard-LA10: What is the significance of an elevated BNP? Is there a range that is relative to the heart failure and how do they treat it?

Dr__Navas: B-type Natriuretic Peptide or BNP is a hormone that is released primarily from the heart. We normally read an increase when a patient is in heart failure and this happens in response to the high pressures inside the heart. BNP above 100 is abnormal. It is a useful tool for patients that present with shortness of breath with unknown etiology. Patients that have established heart failure, it is useful to monitor them, especially in the outpatient area.

nutzy: How accurate can be the B-type Natriuretic peptide blood test for heart failure diagnosis ?

Dr__Starling: B-type Natriuretic Peptide (BNP) should be used in conjunction with a physical exam to make a diagnosis of heart failure. In isolation, the BNP test can be misleading and should be put in the context of the clinical presentation and findings.

Diastolic Dysfunction

chatter: Left ventricle diastolic dysfunction, with high output heart failure causing mild pulmonary hypertension. I was recently diagnosed with this and am trying to be proactive and find what treatments are available to me as the only thing they have done at this time is take me off of norvasc and put me on coreg twice a day as well as increase my lisinopril to 20mg twice a day, yet my BP stays very high, and the heart failure symptoms continue. Any input at all at this time would be helpful.

Dr__Navas: It sounds like diastolic heart failure is causing pulmonary hypertension. You need to get your hypertension into good control. This is the first step of your therapy and then I would go from there.

JudiG: Can you tell me if a 64 yr old female has normal left ventricular ejection fraction of 65-70%, but overall diastolic pattern is one of mild (Gr.1) impairment of left ventricular relaxation with normal left ventricular filling pressure, and left atrial size moderately dilated, could that eventually lead to heart failure? Should echos be done every few years? Appreciate anything you can tell me. All else on echo is normal. Thank you.

Dr__Navas: It sounds by your description of echo results, you have mild diastolic dysfunction. If this progresses, it will eventually cause diastolic heart failure. But in a woman over 60 years old, it is not unexpected to have this degree of diastolic dysfunction on an echo.

Dr__Starling: That echo result is seen very frequently in patients that are being treated for hypertension.

Dr__Navas: It is not really necessary to have echos every few years unless you see some change.

BJD: Should someone with diastolic heart failure be enrolled in a structured cardio rehab program.

Dr__Wolinsky: Patients with diastolic heart failure are excellent candidates for cardiac rehab. All patients with heart failure are good candidates, but the subset of DCM patients often tend to be women who are deconditioned and these people often do very well in a structured cardiac rehab program. The caveat is that it may not be covered by insurance - so it is important to talk to the rehab program and your doctor about the various programs that can be individualized to the patient.

Dilated Cardiomyopathy

vinod: what is the treatment of DCM heart disease.

Dr__Wolinsky: The treatment of Dilated cardiomyopathy or DCM is as described as in other responses. The mainstay includes beta blocker therapy, ace inhibitors, diuretics as needed, and other treatments as dictated by the severity of disease.

Dr__Wolinsky: It is a dynamic treatment which changes with the severity of the disease. It is important to make sure the patient has a diagnosis of DCM and coronary artery disease (CAD) has been ruled out by angiogram and/or stress test.

Valve Disease and Heart Failure

ehbrod: Can a 90 year old patient with serious aortic stenosis be saved with a .3 aortic valve opening? Which procedure would you recommend to save her life. What is the clinical definition of heart failure? In other words what is going on in my heart? I get fatigue, fluid retention and shortness of breath. But it goes away depending on my diet. Therefore, wouldn't an appropriate diet be better than endless medications with all kinds of side effects?

Dr__Starling: Can a patient be helped with a 0.3 valve area? The answer is yes. A patient this age would be considered for aortic valve replacement in the cath lab as an alternative to opening the chest (TAVR). That decision is made on a case by case basis. Increasingly, more patients are being referred for the non-surgical approach in this age range.

It is most likely that your symptoms are from heart failure related to aortic stenosis which impairs the ability of the heart muscle to work normally resulting in high pressure inside the heart which leads to shortness of breath and heart failure if the AS remains untreated. There is no effective medical or dietary therapy for heart disease caused by severe AS.

clara: I have recently been told that the tricuspid valve is severe, and I will need surgery when I can go off Plavix. I recently had the 7th stent. The mitral valve has gone moderate, and I have had the aortic valve replaced. I have SOB / lightheaded / swelling in the stomach that spironolactone helps some. I also read that these symptoms can cause heart failure. I do seem to be getting more SOB and lightheaded. How would I know if it is heart failure?

Dr__Starling: Heart failure is a diagnosis related to symptoms including fatigue, fluid retention and shortness of breath. You may have heart failure - your cardiologist can perform an examination and make sure you are on the proper medications.

Hypertension and Heart Failure

MaryEllenT: My dad has hypertension and heart failure. His doctor changed from metoprolol 100 mg to metoprolol 100 mg ER - is it ok to finish out his current prescription of metoprolol before switching over?

Dr__Navas: It depends on how much of the metoprolol you have left. Ideally you should be on Metoprolol ER. If he has been on the other Metoprolol, two times a day and only have a couple weeks left and he feels ok - it may be ok - but the ideal treatment is the metoprolol ER. He should speak to his doctor.

Heart Failure and Atrial Fibrillation

John-K: I am on 10 mg coreg cr and 5mg altace. Will an increase affect the reduction of A-Fib? What dose do you like to see a patient on?

Dr__Wolinsky: The dose has to be individualized to the patient based on resting heart rate and blood pressure and the ability to tolerate the maximum tolerable doses. Certainly doubling the doses if tolerated would not be unreasonable - if tolerated. An increase may decrease the likelihood of having atrial fibrillation (afib).

palmbeach22: I have atrial fibrillation. 2 failed ablations. Medical management for control of rate and coumadin. I am starting to get pitting edema around the ankles/legs. Worried that my afib is causing my heart to go into heart failure. What should I do?

Dr__Navas: The approach of rate control and anticoagulation is well accepted however atrial fibrillation can cause diastolic dysfunction leading to heart failure. Also, if the rate with afib is not well controlled it can cause tachycardia induced cardiomyopathy. If you are experiencing edema or other symptoms you need to talk with your cardiologist and find out if the symptoms have to do with the atrial fibrillation. If not - you need to find out the cause.

witter123: I had both a-flutter & a-fib since 2007. I have had two ablations and four cardioversions at the Clinic. I have taken Sotalol on two occasions that lasted only a month or so then back out of NSR. I am now on Multaq for over 2 1/2 years and staying in NSR and feel great. I have taken Multaq for 2 1/2 years and find it the only med that keeps me in NSR. I also have Class II heart failure. How will Multaq affect me if later I drift into Class III or IV failure. Sotalol never worked on me and cardioversions never lasted more than a couple of weeks. Thanks.

Dr__Navas: The current recommendations for multaq in heart failure patients are that it is contraindicated in symptomatic heart failure or decompensation or NYHA class 4. The risk of death in these patients is much higher. These were recommendations for United States. In Canada, it is contraindicated in all patients with heart failure regardless of functional class. If you remain in FC II and normal sinus rhythm, you shouldn’t have any problems. But - if you start having symptoms or become decompensated, you could run into problems.

Dr__Starling: I would like to add that some cardiologists choose not to use Multaq in any patients with a reduced ejection fraction, which is a way of emphasizing what Dr. Navas said. We are very cautious with the use of this drug. Close follow up is needed.

Heart Failure and Coronary Artery Disease

Tanya875223: My husband has had 2 heart attacks, 4 stents. He has a 35% EF. Started having shortness of breath, fatigue, and angina. Went to the doctor and they found 2 more blockages and one blocked stent. Medications are not helping his symptoms, wondering if our next step is stents again to open up the blocked arteries or maybe heart surgery because the stents continue to block up or not working. But - maybe surgery too risky for him?

Dr__Wolinsky: Are his symptoms coming from heart failure or from coronary artery disease(CAD)? If symptoms are coming from heart failure, is it because of permanent irreversible damage to heart muscle or weakened heart muscle due to not enough coronary blood flow? Bypass surgery will help those with CAD with evidence of ischemia on testing or inadequate blood supply with testing - but will not help those with permanent muscle damage.

PET scan or cardiac MRI may be needed to assess the underlying pathology that is causing the problems. This will help with the decision to perform surgery or not. If he is felt to be a surgical candidate, the information we have here does not suggest he would be too high risk if the overall benefit would be significant.

John-K: Before and after my Heart Attack on October 1, 2011 (extensive myocardial infarction, coma 4 days, 5 stents with no re-flow), I maintained a healthy lifestyle. I have always maintained my weight, exercised every day, and had low BP and good Cholesterol readings. My Lipoprotein (a) was 66. It is now 56.7. This secondary heart risk may have caused my problem. I now have an ICD and have A-Fib. My EF is around 30. My medicines are the following: 2000 mg Niacin, 150mg Pradaxa, 10mg Coreg Cr, 5mg Altace, 25mg Aldactone, 75mg Plavix, 81 mg Aspirin, 10 mg Lipitor My Questions: My EF from an echocardiogram on 12/23/11 was 34% (+or– 5%) and on 1/4/2013 it was 25-30%. The tests were performed at two different locations. Is this reduction in EF % a reason for concern? Is my heart performance getting worse? My latest LDL result was 56. When I was on 20 mg Lipitor it was 24. What is the ideal LDL with my high Lipo (a)? I still jog 3-4 miles per day in about 40 minutes with a heart rate around 107. Should I be doing more or less exercise? My Lactate Dehydrogenase (LDH) is 259. What should my concerns be and what should my course of action be?

Dr__Wolinsky: First of all you are doing a great job of taking care of yourself and being your own advocate. The exercise you are doing as long as you are comfortable is good for you. The most recent data on exercise and CAD suggests high impact exercise is good for your heart. We know that vigorous exercise decreases mortality by 5 - 10 % so you are doing all that you should do.

Some of the meds you are on are on low dose such as coreg and altace, one could wonder if those doses can be increased depending on your clinical status. As far as the ejection fraction (EF) status, you need to have someone look at both echocardiograms because the EF may be somewhat qualitative and there may or may not be a significant change. And if you were or were not in atrial fibrillation - that could have effected the EF.

As for the lipid reducing therapy, the guidelines suggest treatment with a statin and getting the LDL less than 70 is the goal. I think there is little data to suggest the benefit of niacin at this point of time in someone with CAD who already has their LDL less than 70 but I don't see a role for getting too concerned about the other parameters beyond the LDL at this point.


Highpointer42: I had 4 heart caths in 2012. Angina seems under control, but shortness-of-breath has developed since I was put on Ranexa in Nov. Could Ranexa be a cause of sob?

Dr__Wolinsky: It would be unlikely. Ranexa is used to treat symptoms of CAD whether they are angina or SOB - but it is not a drug that is given to make people live longer or improve survival. So - if you are concerned that the medication is making you feel worse, you should talk to your doctor about changing your medications. More importantly a discussion with your doctor about the results of the cath, including not just the arteries, but pressure measurements for assessment of heart failure would be important to discuss.

Sharon-MN2523: My husband has heart failure - his BP has been low 90s over 50s and he is very tired. Any ideas on what else we can ask his Dr's to do or think about? He is on metoprolol, losartan and lasix. He doesn’t feel any better and basically the doctors are saying we need to wait for the meds to work, raising the lasix as needed. I feel like we should be asking questions but not sure what to ask. Is he on the right medications? Is there anything else we can do? He is only 31 years old and we think had a virus which put him in this situation.

Dr__Navas: You are absolutely on the right medications if the metoprolol is the long acting. It depends on how long he has been on this therapy. We would increase your medications to target levels and then follow to see if you are seeing any improvement. It depends on how long you have been on the medications, if no improvement you may need to have more aggressive interventions to optimize your therapy. There are other types of therapies you may benefit from. Without knowing more, it is hard to say.

Dr__Starling: I agree with everything that Dr. Navas said. My advice is to make sure he has been evaluated by a cardiologist and/or heart failure specialist so that he has the most optimal evaluation and treatment.

HowardW: Is there a better time to take a blood thinner and calcium beta blocker.. morning or night?

Dr__Wolinsky: Most important thing is to take it the same time every day. In certain settings for high blood pressure, it may be better to take it at different times, but you need to discuss this with your doctor - because it depends on the reason these were prescribed.

Joe-R: In 2007 I had a successful ablation there in Cleveland, I have some weakness on the left side of the heart due to the PVC's. I also have a slight aortic regurgitation in my bicuspid valve, which they watch. I have regular echos, but no meds, I am 27 yr old male my ejection fraction is 50. Am I ok do I need medication???? I was on Toprol but off for two months to do a Holter Monitor.

Dr__Starling: Based on the information you have provided it is difficult to make a firm recommendation. Many factors including the size of the heart, any symptoms you may have and past echo findings would influence the decision to use medications for prevention or treatment including a beta blocker and an ace inhibitor. I suggest you discuss any questions or concerns you have with your Cleveland Clinic cardiologist.


SaraLB: My husband is 55 years old, has heart failure, ICD, on a bunch of meds. I am very frustrated as he seems to not care about his diet. He feels his meds will take care of things. I feel like he is being stubborn. Exactly how important is low sodium, low fat diet for this condition?

Dr__Navas: Diet and fluid restriction is an extremely important part of heart failure treatment. Compliance is as important as medications to keep the patient stable and from retaining fluids.


HowardW: Can you give me a reference on how to use a heart rate monitor to improve heart health.

Dr__Wolinsky: A better question is whether it is needed. Your physical conditioning will determine the target heart rate that you need with exercise. Often a stress test is conducted before entering an exercise program. The results can determine what your exercise guidelines should be.

Just using a heart rate monitor alone does not help with activity. There are times when someone’s heart rate goes up rapidly - they would need a program that requires a slow progression with a long term steady rate. Some people with heart failure may also need to have their heart rate monitored with exercise. If a patient is healthy, they need to keep their exercise in the 75 - 80% range and keep with this program. Heart rate target depends on whether they are healthy, their functional capacity, if they have heart disease and if they are on any medications that affect their heart rate.


Albert-K: Is the clinic performing studies with stem cell therapy for heart failure patients and if so, how can I get involved?

Dr__Starling: Yes. the best way to get involved is to see a heart failure specialist. At any point in time it may be variable as far as what protocols are available. This is probably the number one question that is asked. (You may also check and NIH).

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Reviewed: 2/13

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