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Understanding Heart Failure (Drs Navas & Starling 4 22 14)

Tuesday, April 22, 2014 - Noon

Description

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, Cleveland Clinic Florida, and Dr. Starling, Cleveland Clinic Ohio campus, answers your questions.

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Heart Failure – Weakened Heart Muscle General

NanatoKCA: Good morning, I was recently hospitalized and diagnosed with a weaken heart muscle. Will be checking with my Cardiologist next week and I am sure he will answer all my questions, just wondering....is this a completely curable issue or will I struggle with it for the rest of my life?

Viviana_Navas,_MD: The diagnosis of a weak heart muscle depends on what is causing the weakness of the muscle. The causes could be potentially reversible with optimal medical therapy. Even with complete improvement of heart muscle, you will probably need to be on heart meds the rest of your life. If you have chronic heart failure (you do not improve), then you will need to follow up with your cardiologist.

my_joy: CHF is very confusing. I was Diagnosed with CHF as a result of extensive damage to the anterior LV from a MI which occurred 20+ years ago. As long as I take my meds I remain in stage 1-2 most of the time. If I don't take my meds or become ill or excessively tired, it progresses from stage 1 to stage 4. How is this considered stable?

Viviana_Navas,_MD: It sounds that you have chronic systolic heart failure - meaning a chronic weakness of your heart from prior MI years ago. This means that you need to be on chronic medical therapy. It also sounds as though when you take your meds you are stable. When you stop your meds - you will get sick. Stability means stability on medical therapy.

fairgo: Hi. I have had three ablations all unsuccessful, my last echocardiogram a few weeks ago had my LA area as 27.2cm and RA 23.2 cm , PASP is 60mmHg and described as mild but I’m worried that with normal range being 35mmHg it is more than mild and I will be in danger of heart failure in the future. My cardiologist has me on statins 10mg and diltizam 120mg daily but intends doing nothing more as treatment, do you think he is doing enough or are there other tests apart from an echo I should be asking for? Thanks for your advice.

Randall_Starling,_MD,_MPH: If your heart rhythm is controlled, and your echo shows normal valve function, normal pumping function and normal relaxation - the only other areas to address are general risk factors including high blood pressure, abnormal cholesterol level, smoking, exercise and diet.


Evaluations – Second Opinions

Ann-C: I live in Arizona and have a brother here who has been treated for severe CHF with unrelenting PVCs, without success (pacemaker, ICD, coreg, etc.) for almost a year. He is a fit 67 year old man. We have been discussing that it may be time to get a second opinion (his cardiologist has now started talking about a heart transplant as the possible outcome of this scenario). I understand that the CC is considered the best cardiac hospital in the country. Can you tell me how we can go about finding the right specialist for him? He is on Medicare and has Plan F as his medigap insurance. Thank you.

Viviana_Navas,_MD: If he is having refractory heart failure and refractory arrhythmias that do not improve in response to medical therapy, these are indications to undergo transplant evaluation and I agree to bring this up to your cardiologist as a possible option. We are happy to evaluate your brother and if indicated, to start the evaluation.

anncie: My brother developed acute CHF last June. Has a pacer plus defib. EF is only 15% on coreg and other meds. Very big issue is ongoing pvcs...up to 120/hr. has become fairly asymptomatic except for some dizziness and sob. No ankle swelling or respiratory issues. Feels better but his doc mentioned transplant for the first time yesterday. Advice? Could he get a second opinion at your hospital? Age is 68.

Randall_Starling,_MD,_MPH: Yes - we would be happy to provide your brother with a second opinion.

big-dog: I have had LVH since 2003. I have high blood pressure 160/110 and take ACE inhibitors. After shoulder replacement 10/08/13, I was taken to ICU on 10/17/13 with hypovolemia shock, kidney damage and mitral regurgitation. I continue to get worse. Winded just putting on compression socks for edema, rising pulse, rising BP. I saw a cardiologist who prescribed lasix, beta blockers and said I have transitional mitral regurgitation. She didn't discuss valve replacement though. Also, I have Wegener's inflammatory vasculitis. What other treatments should I consider? I am 55 yr. male, also on oxygen because O2 is under 85 while sleeping and 89-92 while awake. Feel as if not everything is being disclosed. Suggestions Please.

Randall_Starling,_MD,_MPH: You have a very complicated situation with Wegeners and oxygen dependence. It sounds as though you have functional mitral regurgitation, which means that the valve is stretching as the heart enlarges and sometimes treatments that help the heart muscle can lessen the leakage of mitral valve. I think that a combined approach between a cardiologist, lung specialist and rheumatologist would be required to find the optimal treatment for you. A complex patient such as yourself might benefit from an evaluation at a large tertiary referral center with multiple specialists working together.

Helpformom: My Mom has had a 2nd aortic valve replacement (2012), and seven months ago had an aortic aneurysm repaired. She also has another aneurysm (very difficult to repair) and not requiring surgery at this time. Takes her meds faithfully. She continues to experience heaviness in her legs (varicose veins), and much fatigue daily. Also has back pain which we have been told is from the two heart surgeries. Yes, she followed the rehab post heart surgeries and does walk almost daily. Could the leg pain be caused by the varicose veins and is the daily tiredness normal? Also, I have read that some generic meds have a variance of 'filler' ingredients up to 20% from the brand name meds. Appreciate your input regarding this. Thank you for your time.

Randall_Starling,_MD,_MPH: Your mom's condition sounds complicated - to really answer your questions would require an office visit and a thorough examination. There may be opportunities to make some adjustments that would make her feel better.


Ejection Fraction

SteveL: I have a low ejection fraction rate of about 30%. What should I expect for a prognosis? Keep in mind I have been going to a personal trainer twice a week for the last three years. I do not have chest pains when I exercise or at rest. The results are from a stress test just recently.

Viviana_Navas,_MD: The actual number of EF is really not the best prognostic indicator - the prognosis is better based on your functional capacity - it sounds like you are able to train without symptoms - which puts you at functional class I. Based on this, currently you have a good prognosis - continue optimal medical therapy and what you are doing.

pbdonnieboy: Just diagnosed with a low LVEF. Previously had Afib- with ablation two and 1/3 years ago, which, along with medication, controlled Afib w/no episodes until this last one. Two and 1/3 years ago, heart Ventricles were good. This recent Afib attack lasted about six days prior to electrical conversion. LVEF discovered thru TEE prior to cardioversion. Question: Is it possible that I may see some recovery, since this was spotted following six days of Afib? Some symptoms were present prior to attack and conversion, but more pronounced now. Besides losing weight, 5'11", 251 lbs. male, what can I do to enhance QOL. I also have sleep apnea, and I am to be scheduled with a pulmonary sleep study. Thanks-Don

Randall_Starling,_MD,_MPH: In most heart failure patients we try very hard to maintain regular rhythm; and to control the speed of the heart rate. Sometimes EF may or may not change but the patient will still feel better if their heart is in regular rhythm. If you have a biventricular pacer it may be especially important for you to have close follow up with your heart failure doctor and electrophysiologist.


BNP

sareptatj: How reliable is BNP in assessing degree of heart failure?

Randall_Starling,_MD,_MPH: BNP is a very helpful laboratory test and is very reliable. It has not been proven to be useful to measure at each office visit to reduce the need for hospitalization. There is a clinical trial ongoing, GUIDE IT - Cleveland Clinic is participating and the trial is designed to determine if frequent measurements of BNP improve outcomes and reduce hospitalizations.


Medications

MarieO: Has Altace in the brand name shown to be more effective than generic when treating patients with Dilated Cardiomyopathy? Has there been any clinical trials to address this? My son has been on Altace and we have been buying the brand name since 2007. Is there any reason that he should take the brand name over the generic name for this condition?

Viviana_Navas,_MD: There is really no clinical trial to show the brand name is better than generic. In fact many of my patients are on generic forms. There is really no reason you cannot take generic.

Trykkergirl: Can medicines be taken to help prevent worsening of heart failure and to help raise your EF?

Randall_Starling,_MD,_MPH: Yes - ace inhibitors and beta blockers are the cornerstone of treatment and can lead to improvement of EF and quality of life and outcomes.


Surgery

tinka: Is there an operation on the heart to fix the heart failure situation.

Viviana_Navas,_MD: If your heart failure is caused by valve disease, yes - surgery could help to either repair or replace the valve. If your heart failure is caused by CAD (coronary artery disease), then that can be corrected with bypass surgery and that can also improve heart failure. There have been different types of surgery that have been tried for enlarged or weak ventricles, but the results have not always been positive in helping improve heart failure by a weak and enlarged ventricle. Currently these procedures are not being recommended for heart failure patients.

DanT: Dear Cleveland Clinic, I have a 63 year old female friend who underwent successful quintuple bypass surgery two years ago, but was recently hospitalized for over 60 days and diagnosed with congestive heart failure. She proved ineligible for a heart transplant and chose not to have a VAD. She has been given approximately six months to two years to live with this degenerative condition. I was told by a friend who used to work for Cleveland Clinic that there is a procedure which involves putting some kind of "band" around part of the heart (mildly invasive) so that the heart does not have to work so hard to do its job of pumping blood throughout the body, thereby extending the life and quality of life for the patient. I could not find anything about this on your website, so was wondering if you could tell me if such a procedure and device exists, and if so, if it might be something she could look into having done. Thank you.

Randall_Starling,_MD,_MPH: Cleveland Clinic participated in clinical trials with the ACORN cardiac support device. This wrap around the heart showed promise as a treatment for heart failure. The FDA did not approve the device and the company is out of business. There is another device that goes inside the heart called the "parachute device" This device is only available based upon strict inclusion and exclusion criteria in a clinical trial. We do not have any "bands" that we are using at this time.

soniacheema: Hi doctor. My brother had constrictive pericarditis due to tuberculosis and underwent pericardectomy in Dec. 2013. Recently, he was again admitted for excessive fluid in his legs. He was referred to the hospital for transplant but doctors said he is not eligible. I am not living with him so i don’t know why he is not eligible. Does that mean he needs a heart but can’t get one or he doesn't need one? He recently was diagnosed with hep c and taking medication for that. His doctors have told him that he will not get normal. I am really confused as what to think of all of this? Is he in multiple organ failure?

Viviana_Navas,_MD: Based on the scenario - two things come to mind. With no improvement after pericardiectomy, that means either they were not able to complete the pericardiectomy and he may still have some constriction. This may be causing his symptoms. The second thing, after the pericardiectomy, he could have developed biventricular failure or tricuspid regurgitation that is why he is having the symptoms he is having. If he underwent an evaluation for transplant that means that he may not improve with other treatments. They told him he was not eligible for transplant - that may mean that he needs a new heart but can't get it. Without knowing your brother's case, it is difficult to say. We would need to evaluate your brother to know more.


Stem Cell Therapy

my_joy: Given that CHF is most often derived from damage resulting from MIs. All cardiac stem cell research being done on humans call for people who have had recent MIs so that the damage is fresh. Would it not be just as expedient to use radio frequency as in an ablation to create a freshly damaged area to introduce stem cells to or to people who are having other forms of heart surgery? Most of these people have had angiograms where tissue can be collected for biopsy and cultivation. The ability to standardize the damage and potential repair would be easier to quantify. It seems that if a damaged area could be reduced then overall improved function would result reducing the need for LVADs or transplant.

Randall_Starling,_MD,_MPH: Thank you for these very insightful comments. We are at the early stages of fully understanding how stem cells will benefit our patients. Much remains to be learned regarding the type of cells, dosage of cells, and the optimal route of delivery, and adjunctive treatments that might enhance stem cell engraftment. Your ideas are provocative and research continues at Cleveland Clinic and around the world.

VinnieC: Can you tell me about a stem cell procedure from bone marrow where the stem cell is trained to seek out the heart muscle and then reinjected to rejuvinate the heart muscle.

Randall_Starling,_MD,_MPH: This sounds like SDF, which is described as a homing factor, which helps to direct the population of new cells in damaged areas in the heart muscle. Those clinical trials have shown promise and are ongoing. In the case of a heart attack, early injection of cells appears to be an important strategy.

dalailama: Patient age 73 y/o male. MI in 2000. Current EF 30%. Present condition managed with Coreg, Enalipril, Lipitor and Aspirin. ICD in place. Recent (Feb.) check-up indicates no further therapy at this time. I am very active with exercise and diet restrictions, BMI 26. Question: In order to relieve side effects of Coreg and Lipitor should I pursue participation in a gene therapy trial? I understand that someone at Mt. Sinai, in New York, has established his ability to grow heart muscle tissue and vascular tissue and that NIH trials have been approved (fast tracked) however, recruiting has not yet started. Thank-you for your answer. Darryl

Randall_Starling,_MD,_MPH: The cornerstone of all heart failure trials with stem cells or surgical therapies or devices - is medical therapy. I think the hope that a stem cell program will eliminate the need for beta blocker is highly unlikely.


Supplements and Vitamins

datepitam: I was diagnosed grade I/IV with preserved EF at ECHO Doppler in 2008. In December 2013, I am diagnosed initial enlargement of LV and prescribed Tritace(Ramiprilum) 2,5mg/day. I successfully control cholesterol taking Simvastatin 20mg/day. I am not diabetic,171cm/79kg, have no hypertension, never had cardiac infarction. I have minimal mitral regurgitation. I am aware my type of heart failure is the least researched and understood. Japanese researches use curcumin as a new treatment for diast.dysf. Application of curcumin to heart failure therapy by targeting transcriptional pathway in cardiomyocytes www.ncbi.nlm.nih.gov/pubmed/23302632. Theracurmin has bio-availability of curcumin by up to 27 fold. circ.ahajournals.org/cgi/content/meeting_abstract/124/21_MeetingAbstracts/A14380?sid=869a0223-26fd-4a43-aefb-64fd9f001165. I shall get the latest 185 fold soluble curcumin in April.What is your take on it and dias.disf. reasearch on BH4, N-Acetyl Cysteine, Idebenone, CoQ10?

Randall_Starling,_MD,_MPH: In this particular patient's case the US and European guidelines would suggest that you treat any underlying diseases, which you do not have. It looks like the only abnormality is initial enlargement of LV, you may wish to get another opinion and follow-up echo - you may not require any medication at this time. We don't have enough information to be more specific. In addressing the question of supplements, there is no research that shows that supplements do help patients.


Hypertrophic Cardiomyopathy

xdwl: Hi, doctor. I am a 56 year old female with HOCM and underwent septal myectomy two years ago. My LVOT obstruction has been well eliminated. I feel quite OK (NYHA II) and can travel around after the surgery. However, during the winter in past two years, I always felt chest discomfort, and feet mild-mod swollen. Since each Apr., I feel much better. My recent echo shows: LV AP Dimension of end-diastole 50 mm, end-systole 33 mm. EF 64%, mild-moderate AR, Baseline LV diastolic function is consistent with abnormal relaxation (stage-1). I would appreciate your advice: 1) My doctor put me on Metoprolol Succinate and spironolactone. Is the treatment appropriate for my condition? 2) Since my symptoms are more obvious in the winder, I tested serum 25-hydroxyvitamin D 22 ng/ml (range 30-74). I do not do much outdoor activities. So, should I take Vit D3? Can Vit D3 improve heart function? 3) I read articles that COQ10 may protect/improve heart function. Should I consider it as well? Thanks a lot!

Randall_Starling,_MD,_MPH: 1) Those medications seem reasonable. 2) If you are low in vitamin D, it would be reasonable to take a Vitamin D supplement but it will not improve your heart function. 3) There is no evidence at this time that COQ10 will improve heart function and it can be costly.

xdwl: Hi, doctor. My question is on whether NYHA II is associated with my symptoms. I am a 56 year old female, with HCM > 10 years. I had septal myectomy two years ago and LVOT obstruction has been well eliminated. I feel quite OK (NYHA II) and still can travel around. However, I started feeling chest discomfort (stuffy chest) 18 months ago, with no clear reasons. Occasionally I feel mild lightheadedness, and had very mild feet swollen. BP 95/65, HR 55bpm. Chest discomfort is not associated with exertion, no chest pain, and I can still lie flat. My recent echo shows: LV AP Dimension of end-diastole 50 mm, end-systole 33 mm. EF 64%, mild-moderate AR, Baseline LV diastolic function with abnormal relaxation (stage-1). 48 hours holter did not show significance. I am on Metoprolol Succinate 23.75mg/day. Would NYHA II cause my symptoms of "stuffy chest" and occasionally feeling of mild lightheadedness? I am with HCM, should I take ACEI as well? Any other treatment for my symptoms? Thank you very much!

Randall_Starling,_MD,_MPH: Based on your current symptoms, I would suggest you have a visit with your cardiologist for re-assessment of your condition and medications. I would not recommend an ace inhibitor until you have a visit with your doctor.


Valve Disease

kahuna8: I have severe aortic valve stenosis, age 77, male, no previous acute cardio problems. My question relates to delaying surgery for AVS vs. onset of age related heart disease. I prefer TAVR, but my STS score is estimated at one or two, so therefore not eligible at this time, but perhaps within a year? My overall health is very good. No symptoms - I find it very difficult to choose to go ahead with Open Surg., with the associated risks, etc. THANK YOU.

Randall_Starling,_MD,_MPH: There are specific guidelines in the U.S. as far as timing of aortic valve replacement and those recommendations are based on echo parameters as well as assessment by a cardiologist. I would recommend that you either seek a second opinion or follow the recommendations of your cardiologist as far as surgery vs. TAVR. You would not be eligible at this time for TAVR being low risk. It is generally not wise to wait to get worse for an operation.

SandiB: Had an echo that showed I have severe mitral regurgitation and tricuspid regurgitation with severely elevated pulmonary pressure and severe left atrial enlargement. Ejection fraction was 55%. Grade 3 diastolic dysfunction. I have been short of breath and not able to do the same things I normally do without getting tired. If I get the valves fixed will that help the diastolic dysfunction and symptoms.

Viviana_Navas,_MD: The degree of TR and MR are very accurately assessed by an echocardiogram but when there is severe MR it is hard to grade the diastolic dysfunction. So grade 3 diastolic dysfunction - would not be necessarily accurate in this setting. However, it does seem as though your symptoms are secondary to valve disease and I believe at this time it sounds like it would be indicated to have valve surgery.

jamesd: Having had an Aortic Valve replaced in April 2009, and having seen my Cardiologist each year since, I was wondering if there is something more that can be done to insure I am not having valve problems again. Ultra sounds are about all that is done each visit. I can’t do a stress test as my knees will not support the effort needed. Want to be sure I am not having other issues. I feel fine and at this time have no real heart limitations at 73. No faintness, no real energy lose etc. Thanks.

Randall_Starling,_MD,_MPH: A yearly echocardiogram is exactly the appropriate evaluation for you to have - there is no other specific testing that is necessary. If you are developing symptoms of any sort such as chest pain shortness of breath, dizziness, your cardiologist would investigate further. Practice a general heart healthy lifestyle - diet, exercise and attention to routine medical problems.

JaiJune: I had mitral valve replaced 18 mos ago. Six mos. later after an echo i was told my tricuspid now has moderate leak, also right lower chamber is enlarged and I am in early, mild HF. My cardiologist sees me every six months. Is that the standard? What tests do you recommend and now often? What medications? I am on lasix, 20 mg twice a day. Thank you.

Viviana_Navas,_MD: It is not uncommon for patients with MV disease to have some degree of TV disease and more commonly TR. If the regurgitation is moderate and you are only having mild heart failure symptoms it is appropriate for a cardiologist to see you every six months. The follow up of TV regurgitation and right sided function should be performed with an echocardiogram and followed clinically. I agree with the dose of diuretics if 20 mg twice a day is helping you - that is adequate. That could be increased if you require more of that. If you are having right sided failure symptoms from TR and the dilated right sided chambers, spironalactone or other diuretics could also possibly help with your symptoms.

clara: I had heart surgery replacing aortic valve and two grafts. Since then, eight stents in all major arteries. I now am told that the tricuspid valve needs replaced. The mitral valve has changed to mild/moderate. I was told if I wait too long I could go into heart failure.

Viviana_Navas,_MD: The decision to replace the tricuspid valve is based on clinical symptoms and echocardiographic finding. If the MV regurgitation is only mild-moderate I don't believe that would need replacement; unless you have echo findings that are indication for TV replacement. If you are asymptomatic the correct treatment would be only follow up at this point. I think you need to ask your doctor what the indication for TV replacement would be besides severity.


Pediatric Question

Shankar: My niece of nine years of old is suffering from heart pain for few seconds and again get recovered and start playing. And again after one to two hours, getting pain for few seconds and get recovered soon. This has been occurring since yesterday, and we visited doctor and taken scan and no issue was reported from scans but still she is feeling the same. Can I know the exact reason and whom should I contact for this to be recovered?

Viviana_Navas,_MD: Not every chest pain is cardiac pain - so it could be muscular pain. If she keeps having pain - she should see his pediatrician. And if the pediatrician deems this necessary she should see a pediatric cardiologist.

Reviewed: 04/14

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