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Heart Failure & Treatments (Dr Mountis 4 2 13)

Maria Mountis, DO

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

Tuesday, April 2, 2013 - 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. Maria Mountis answers your questions about Heart Failure and treatments.

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Definitions and Types of Heart Failure

Janerww: Could you update us on the latest research/time frames for new HF treatments? Also could you explain how right sided HF causes ascites and how to detect it early? Is there anything other than daily weights?

Maria_Mountis,_DO: Research for heart failure therapies is ongoing. It may take months to years before we, as physicians, can implement the findings of research. We are up to date with all the current research therapies available at the Cleveland Clinic. Right sided heart failure simply is right side of the heart unable to pump appropriately to the lungs and therefore to the right side of the heart. Typical symptoms are abdominal bloating and lower extremity swelling. Being evaluated by a specialist is really the best way to diagnose right sided heart failure. Potentially digoxin and a diuretic combination of torsemide and aldactone can help to treat ascites.

Txgirl: My mom is 70 years old and has right sided heart failure. She is being treated but still can't get rid of her swollen ankles in spite of water pills and other meds. Can you explain right sided heart failure and what the right treatment is for this?

Maria_Mountis,_DO: We discussed right sided heart failure earlier in this chat. Including to what we discussed, she should wear support stockings and elevate her legs as often as possible. Also - watch her sodium and fluid intake.

KellyG: Is heart failure and cardiomyopathy the same thing? Do you die from this?

Maria_Mountis,_DO: Cardiomyopathy is a generic term meaning weakening of the heart muscle. This can have multiple etiologies; including coronary disease, long standing high blood pressure, viruses, chemotherapy and many other reasons. Heart failure is the potential symptoms of a cardiomyopathy.

Terra: Hi - Thank you for considering this question. Would you please explain the relationship between low diastolic filling, ejection fraction and heart failure.

Maria_Mountis,_DO: We describe what heart failure is in the above question. Ejection fraction is the percentage of blood that leaves the heart every time the heart pumps. Normal EF is about 50 percent.

NancyL: I see information on systolic and diastolic heart failure but then what is dilated cardiomyopathy and ischemic cardiomyopathy. I have seen all these terms but confused by how they are related and what they mean.

Maria_Mountis,_DO: Cardiomyopathy is a generic term of weakening of the heart muscle. Dilated cardiomyopathy means the heart muscle has enlarged. Ischemic cardiomyopathy is caused by blockages in the arteries of the heart or prior heart attacks. Ischemic cardiomyopathy can progress to a dilated cardiomyopathy as well over time.

Systolic heart failure occurs when there is poor squeeze of the heart and diastolic heart failure implies that the heart function is unable to relax well. Many can have both at the same time.

Ejection Fraction

J@CC: Heart failure patient (3 lead pacemaker) implanted. LBB, low EF caused by viral infection. Tests (catheterizations and echos) reveal no signs of cardiovascular disease. I pass all stress test (times out without having to stop), very active playing tennis 3 times a week, and walking 4 miles (moderate pace) 3 times a week. Test reveals EF 25-30 but no symptoms. My question is, could I have one EF at rest (that is when it checked) and another higher during exercise. Doctors are amazed at my exercise tolerance.

Maria_Mountis,_DO: You are doing wonderful. The EF is not the only marker of how well someone does; in fact your functional capacity is a better marker and overall gives you a better prognosis. Cardiac output certainly changes with exercise but EF can stay the same. Keep doing what you are doing.

CE2237: I am 45 year old African American male with cardiomyopathy, EF of 15%, I have an ICD. I have had this for 8 years. I have been managed pretty well with meds other than a couple episodes treated by my ICD. I am wondering about the next phase. How long can someone be managed on meds with my EF? What will happen if a transplant is needed? I know I am not sick enough now but how much harder is it to get a transplant as I get older?

Maria_Mountis,_DO: It sounds like you are doing very well! We certainly manage patients with low EF like yours for many years - the key will be to follow with your cardiologist at least yearly and to at least be evaluated by a heart failure specialist in case you need advanced therapies. You are still very young - we do have many options to treat patients with other than transplant including adjustment of medications and ventricular assist devices as well.

JR745: After AICD placement, how soon would it be suggested to have another echocardiogram? With an EF of 30%, is it still possible to have a child?

Maria_Mountis,_DO: ICD placement will not affect the ejection fraction. I would recommend an echocardiogram about once per year. In regards to pregnancy, this is very individualized. You would be considered high risk with a lower EF but would have to discuss your situation with your cardiologist.

KzooBuckeye: I had successful mitral valve repair surgery in 2009 at the Cleveland Clinic. I was 49 at the time and I am female. My cardiologist didn't think I needed cardiac rehab and I was back to work in 3 weeks. In the fall of 2012 I had my first echo since surgery and my ejection fraction was 45. I am otherwise healthy, good weight, low to normal bp, etc. He put me on 10mg CoregCR and Lisinopril. Any idea what would have caused this drop and could it be because I never really did any rehab? Can I get it to improve? I cardio exercise about 3 days/week at the gym. I was shocked. I thought the valve repair would prevent this problem as I get older.

Maria_Mountis,_DO: Your ejection fraction of 45% is in the low normal range. Not completing cardiac rehab did not contribute to this. I agree with your physician who started you on an ace inhibitor and beta blocker. It sounds as though you are doing very well and I would continue to follow closely with him.

RonD: How is it that some people have an EF of 35%+ and have a very poor quality of life and others with an EF of 10-15% have a good quality of life with normal activities?

Maria_Mountis,_DO: That is an excellent question. There is much more to heart failure symptoms and functional capacity than just ejection fraction. There are many prognostic indicators for how heart failure patients do including various lab tests; amount of diuretic needed; exercise capacity. Some has to do with combined systolic and diastolic dysfunction vs. systolic dysfunction alone.

Heart Failure Symptoms

Aslamkhan_2269: What are the basic symptoms of heart failure?

Maria_Mountis,_DO: Heart failure is a combination of symptoms - where the heart is unable to provide appropriate blood flow to the rest of the body so symptoms can vary including shortness of breath; fatigue; lower extremity edema; build up of fluid in the body.

nutzy: I have had in my childhood rheumatic fever. 10 years ago I had undergone mitral valve replacement with a prosthetic one plus Maze procedure, but my atrial fib became permanent. My cardiologist changed my rhythm control treatment to a rate control one: beta blocker calcium channel blocker, and valsartan for high blood pressure. I can't say that I’m happy with this treatment. I have sometime breathing problems, very tired...thinking about heart faillure. MAYBE I NEED A BNPTEST to be sure what stage of HF it is. I am67years old.

Maria_Mountis,_DO: I recommend you have follow up with your cardiologist or a heart failure specialist to look at your mitral valve again but certainly to make sure you are on appropriate medications. Your shortness of breath could be due to arrhythmia or heart failure. I agree a BNP test is one that I would also recommend.

clara: Would I have shortness of breath, lightheaded feeling, and fluid retention in the abdomen and sometimes fatigue with severe tricuspid disease? The mitral valve has progressed to moderate. Would that cause symptoms. I have had open heart surgery that the aortic valve was replaced (tissue valve) & grafts. I have 8 stents since then.

Maria_Mountis,_DO: Yes - tricuspid valve regurgitation over a long period of time can progress to causing right ventricular dysfunction and symptoms of swelling in the abdomen and legs - and low blood pressure. You really need to see your doctor.

sharadk: My Mother (55years) is a patient of MS who had undergone Open Mitral Valvotomy 20 years age. Since then she is on digoxin, warfarin amiloride+furosemide and aspirin. She had stroke 10 years ago but not affecting her physical activities. Now she has shortness of breath and her echo revealed Severe MS, Mild MR AR TR, estimated PASP is 76mm Hg and LVEF is 55%. The cardiologist told us to restrict salt diet and increased the dose of diuretic. Is there anything else that can be done like surgery or add other medicines? I would be very grateful if you could help us.

Maria_Mountis,_DO: I would refer her to one of my surgical colleagues to see if she is a candidate for mitral valve surgery. jean2: I am 77 year old active female. Diagnosed with heart failure with heart cath in late Nov. 2012. Minimal blockages had not progressed since a 1996 heart cath. Echogram the previous year showed EF of low 40's. I'm not sure what EF was at time of heart cath. This cath showed Heart not pumping well enough to handle things resulting in severe short breath with walking or exercise and on occasion, chest/arm pain stopped by chewing aspirin. Had been on generic Hydrochorothizide 12.5 mg for several months. Dr. added Coreg 3.5 mg; and Isosorbide 30 mg. Very soon, diabetes with no meds, diet controlled. Dr. added Lisinopril 2.5. In March, Coreg upped to 6.2 mg. That helped but still feel that I need more help. Should Isosorbide be upped or are there other meds that would be better control? I also feel that my upper abdomen is expanding, causing discomfort so I wonder if I'm holding more fluids. I cough quite a bit, feel full quickly, but family dr. says lungs sound good. Intend to see the cardiologist next week. Any suggestions would be helpful.

Maria_Mountis,_DO: With the symptoms that you are describing you should be evaluated by a heart failure specialist or your cardiologist. You probably need to be on a diuretic therapy to help with the abdominal bloating and to have adjustment of your medications.

my_joy: Do you notice and if so, treat women with CHF differently when they are still cycling menstrually? personally the problem with water retention and bloating is extremely hard to manage.

Maria_Mountis,_DO: That is a great question. We certainly can adjust the diuretic regimen as needed for each patient based on their symptoms.

Blood Pressure

adelle: have heart failure and on several medications. I am wondering how low is too low for blood pressure. my numbers has been as low as 80/50 and my doctor is not really concerned.

Maria_Mountis,_DO: As long as you are not having symptoms of dizziness or lightheadedness and you are getting appropriate blood flow to the other organs in your body, we tend to keep blood pressure low in order to get benefit from the medicines you are on. If you are symptomatic you should speak to your doctor.


CLStar: Does torsemide and hydrochlorothiazide mess with your potassium like lasix does?

Maria_Mountis,_DO: Torsemide is in the same class of medications as lasix so low potassium is a potential side effect. We typically recommend potassium supplement with this as well.

CLStar: I recently had ultra-filtration done because of having put on 20 lb. Was only on 60 mg of lasix, but apparently built up a tolerate to it. Now having lost the weight, they put me on 240 mg of lasix. Isn't that a bit high dose.

Maria_Mountis,_DO: every patient requires a different amount of diuretic to keep fluid off of them. 240 mg of Lasix a day is a high dose - perhaps you could discuss with your cardiologist using alternative stronger diuretics such as combination of torsemide and hydrochlorothiazide.


CLStar: Wouldn't ultrafiltration help this women with right side heart failure?

Maria_Mountis,_DO: My colleague Dr. Hanna is currently running a trial using ultrafiltration - there are certain inclusion and exclusion criteria. We would be happy to evaluate patients with right sided heart failure but many tend to have low blood pressure and unable to tolerate ultrafiltration.

Heart Failure Doctor

stephiek: I have heart failure from past blockages, high blood pressure treated, high cholesterol treated and diabetes treated. I see a primary care doctor but have been having more short of breath lately and wondering if I should see a heart failure doc. I have seen this doctor for many years. would it help to see a heart failure doctor and then do I keep my primary care - how does that work?

Maria_Mountis,_DO: Absolutely you do need to keep your primary care physician as they are the coordinator of all of your specialists. With your symptoms, I would also recommend you make an appointment with a heart failure cardiologist and they will communicate and work with your primary care physician.


Robert: Do you currently offer stem cell therapy for advanced heart failure other than the clinical trials. Thank You.

Maria_Mountis,_DO: No - stem cell therapy is currently in research trials. We have these trials available to our patients but each patient needs to be screened to see if they qualify.

MichaelA: I am in stage c- CHF, and, I wonder if there is an active research program using stem cells to 1) Regenerate damaged heart tissue. I also have Cardiomyopathy, so, 2) Is there ongoing research using stem cells harvested from my own body, if so, how can I be evaluated to see if I qualify for study?

Maria_Mountis,_DO: This was answered above.


JR745: After AICD placement, how soon would it be suggested to have another echocardiogram? With an EF of 30%, is it still possible to have a child?

Maria_Mountis,_DO: ICD placement will not affect the ejection fraction. I would recommend an echocardiogram about once per year. In regards to pregnancy, this is very individualized. You would be considered high risk with a lower EF but would have to discuss your situation with your cardiologist.

jam111: I am 5 years out from heart tx -- I would like to know your recommendations on follow-up visits and necessary procedures i.e.: biopsies etc... after that period of time.

Maria_Mountis,_DO: After the 5 year mark, we routinely see patients every 6 months. We don't perform any more biopsies unless symptoms suggest we need to.

jam111: Do you recommend or use Allomap to evaluate for rejection?

Maria_Mountis,_DO: Yes we do use Allomap. We traditionally recommend it to patients after 6 months post transplant as long as they have had no rejection, off of steroids and are on stable doses of immunosuppression medications.

Risa: Do you have a large percentage of heart patients who are off steroids?

Maria_Mountis,_DO: We try and wean all of our transplant patients off of steroids within the first six months to a year. Patients who are transplanted greater than 10 - 15 years ago may continue to be on low dose steroids due to change in immunosuppression regimen.

hearttxp98: I am 15 years post heart transplant From the CCF program. Also Had a lad prior to tx. Thanks to All in Cleveland!

Maria_Mountis,_DO: Congratulations! So happy you are doing well!

Bypass Surgery and Heart Failure

PH886675: My husband has a blocked artery 90 percent of which a stent was placed in the left ventricle of upper heart 5 years ago At this time his heart is severely weak and the option was to have a by pass whereas I feel another angioplasty with stent would be an intervention to open the artery to get adequate blood flow until his heart gets stronger He also has diabetes. The cardiologist respectfully understand our rationale for this over by pass .I feel that with a weak heart (severely) I do not know what his chances for survival would be It is only us three me ,,my husband and my daughter and we are afraid of losing him. Can you tell me if the by pass would be the choice given the severity of his heart function or the angioplasty would be a safer intervention until his heart got stronger and then his diabetes could be monitor more closely to reduce the risk.

Maria_Mountis,_DO: When a patient has diabetes along with coronary artery disease and severe weakening of the heart muscle, there is better evidence that bypass surgery is more beneficial than angioplasty alone. In your husband's case though, with a severely decreased pumping function of the heart, he would need to be evaluated for myocardial viability and whether bypass surgery alone is appropriate or to also consider ventricular assist device therapy as a back up to bypass surgery. We would be happy to evaluate him.

National Organ Donation Month

Moderator: Dr. Mountis, as part of the National Organ Donation month, is there a message that you would like to communicate?

Maria_Mountis,_DO: There are thousands of patients living with heart failure. Many of whom have advanced heart failure. Transplant numbers have been very stable over the last few years in the range of about 2000 heart transplants per year. We are fortunate to have technology such as ventricular assist devices that are approved by the FDA to help bridge sick patients to heart transplant or to assist patients life-long with their heart failure as destination therapy. We have information on our website on heart failure. LVAD and transplant. We would be happy to see patients for a second opinion or review.

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: 4/13

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