Treatment of Heart Failure (Dr Mountis 1 27 10)
Wednesday, January 27, 2010 - Noon
Maria Mountis, DO
Associate Staff in the Division of Cardiology, Section of Heart Failure and Transplantation.
Heart failure affects nearly five million Americans, and about 550,000 people are diagnosed with heart failure each year. With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. When this occurs, the heart cannot pump enough oxygen and nutrients to meet the body's needs. There are many ways that heart failure can be treated including medication and surgery, including ventricular assist devices and transplantation. Maria Mountis DO discusses heart failure and its treatment options.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Maria Mountis on Heart Failure. We apologize for the confusion - this chart is for Heart Failure and not Hip Resurfacing in the introduction. We are thrilled to have her for this chat. Let’s begin with the questions.
Speaker_-_Dr__Maria_Mountis: Thank you for having me today.
Heart Failure – General Questions
xosamxo: My sister had successful valve surgery a couple weeks ago but then this week had to go to the emergency room for shortness of breath, edema. Is that heart failure? IS that a bad sign after heart surgery?
Speaker_-_Dr__Maria_Mountis: Her symptoms could certainly be heart failure but without further information it would be difficult to comment. Usually after open heart surgery there are shifts in volume and patients may need diuretics for a short period of time while she recovers. She should speak to her cardiologist and surgeon.
Janerww: Is there a national organization that lists heart failure specialists by state?
Speaker_-_Dr__Maria_Mountis: Many cardiologists who have specialized training in heart failure belong to the Heart Failure Society of America and the American College of Cardiology - but I don't think they list cardiologists by state. Any large cardiology center will have heart failure specialists.
ttyl54: My husband was diagnosed with heart failure - he was told to be on a low sodium, low fluid, and low fat diet - but what foods should he eat and also are there foods that would help make his heart stronger
Speaker_-_Dr__Maria_Mountis: You are correct that he should continue to follow a low sodium and low fluid diet. He should continue a balanced diet with fruits, vegetables, grains and lean proteins. We have a Preventive Cardiology section staffed with dietitians that can help you with food choices.
Janerww: In addition to this website, do you recommend any others for patient and family education? We are appreciative of all of the information that you are giving us. Thanks.
Speaker_-_Dr__Maria_Mountis: The American Heart Association has a great deal of information for patients and caregivers. http://www.americanheart.org/
Janerww: How does one know if one has "advanced heart failure" versus an acute HF episode?
Speaker_-_Dr__Maria_Mountis: Advanced heart failure is a chronic process that a patient will experience over a long period of time. This is in contrast to an acute episode.
gregr: Hi. I was diagnosed with heart failure in October with an EF of 15%. My general doctor said he could handle my medications, blood pressure and monitor my health. Should I also see a heart failure specialist?
Speaker_-_Dr__Maria_Mountis: Absolutely. I think your general doctor is doing a wonderful job but seeing a heart failure specialist at least once may also provide you with information that may not be well known to the general practitioner.
Medical Management of Heart Failure
henett2: Any new medications for treatment of heart failure with high blood pressure and atrial fibrillation?
Speaker_-_Dr__Maria_Mountis: Both high blood pressure and atrial fibrillation can lead to heart failure if not well controlled. We currently have excellent medications in treating both of these conditions including ace inhibitors and beta blockers. If patients are resistant to current therapy then I would recommend a referral to a heart failure specialist as well as an electrophysiologist.
smith77: My mother's doctor suggested a disease management program - what's the benefit of going to that along with a doctor visit?
Speaker_-_Dr__Maria_Mountis: A disease management program entails working with heart failure nurses and nurse practitioners as well as nutritionists and cardiac rehab specialists. I think a disease management program is an excellent resource for patients with heart failure to educate them about sodium and fluid restrictions and may be beneficial for her along with her regular doctor's visit.
sassy: Is it possible with an EF of 20 or less to lead a somewhat normal life just by taking oral medications. Is there any long term prognosis with just medications?
Speaker_-_Dr__Maria_Mountis: Yes it is possible with a low ejection fraction to have a normal functional capacity meaning ability to perform activities that you would like. We look at how a patient feels and not just their ejection fraction. Evidenced based medications such as ace inhibitors and beta blockers do help increase survival.
Janerww: Is there a protocol for achieving target doses of medications? Is this posted anywhere?
Speaker_-_Dr__Maria_Mountis: That is a great question. Heart failure specialists are trained in up-titrating specific medications for heart failure and needs to be done slowly in order to insure safety. We follow guidelines for management of heart failure through the American Heart Association and American College of Cardiology.
Cardiac Resynchronization Therapy (Biventricular Pacemakers)
blueeyes: What tests criteria should be used to determine if a bi-ventricular pacemaker will help congestive heart failure?
Speaker_-_Dr__Maria_Mountis: Once an individual is on evidenced based medicines but still have advanced heart failure - criteria for biventricular pacemaker is a wide QRS by EKG, which shows evidence of dysynchrony. We have an ongoing trial that Cleveland Clinic is a part of called ECHO-CRT, which enrolls patients with advanced heart failure with a narrow QRS but with evidence of dysynchrony by echocardiogram. Your cardiologist will be able to screen for enrollment criteria and we would be happy to discuss further.
sassy: I am a 53 year old female that was diagnosed 9 months ago with dilated cardiomyopathy with left bundle branch block. My EF is less than 25 (originally it was less than 15). I am currently taking Coreg, Lisinipril and Coumadin. My last echo did not show any significant improvement and transplant has been mentioned several times as an option. I was wondering if there are any stem cell clinical trials that I may qualify for or if other devices might help. Right now I feel like I am just taking 4 pills a day and not being aggressive enough in treatment. Any thoughts?
Speaker_-_Dr__Maria_Mountis: So you are on two great medications for cardiomyopathy with the ace inhibitor and beta blocker and if not already tried - you may benefit from spironolactone and with your LBBB I would recommend cardiac resynchronization therapy. Further evaluation by a heart failure specialist should be sought out.
Regarding stem cells - we have three ongoing trials with different eligibility criteria. So to inquire further I would suggest you make an appointment with a heart failure specialist.
sassy: what is cardiac resynchronization therapy?
Speaker_-_Dr__Maria_Mountis: In your case with Left Bundle Branch block - this can lead to dysynchrony or abnormal contraction of the heart. Cardiac resynchronization therapy is a device implanted by electrophysiologists (heart rhythm specialist) where there are at least 2 leads implanted in the heart to help synchronize contraction of the heart and therefore improve the pumping function of the heart. The device is similar to a pacemaker.
Janerww: How long has cardiac resynchronization therapy been used for LBBB? What are potential complications with this surgery?
Speaker_-_Dr__Maria_Mountis: We follow guidelines published by the American Heart Association and the American College of Cardiology to treat patients with heart failure. Cardiac resynchronization therapy has been studied in multiple trials and is an approved therapy for advanced heart failure and patients with a LBBB. I would refer you to an electrophysiologist for your risks and benefits for this procedure.
Defibrillator and Heart Failure
karenw: I had valve surgery two times due to rheumatic fever when I was a child. I am now 65 years old and have an ejection fraction of 20 - no heart failure symptoms at this time. I was told I need a defibrillator but nervous to go through the surgery - I am on coumadin and not sure what I should do.
Speaker_-_Dr__Maria_Mountis: Indications for a defibrillator include patients with an ejection fraction of less than 35 percent who are on goal doses of medications including ace inhibitors and beta blockers. People with a low ejection fraction are at increased risk for abnormal heart rhythms and this is used to shock their heart should a life threatening rhythm occur.
jared: My uncle is a year-old man with NYHA Class II-III heart failure, non-ischemic cardiomyopathy. Wonder what your age cut off is for transplant
Speaker_-_Dr__Maria_Mountis: We don't have a specific age cut off for transplant but an individual, should they have other co-morbidities, including diabetes, renal dysfunction, and vascular disease should all be well controlled. We save cardiac transplantation for patients with advanced heart failure usually with NYHA class III - IV patients, where they already have been on evidenced based medications.
Remodeling of the Heart
oldblueeyes: Dr. Mountis, Once a heart is enlarged is permanent damage done to it?
Speaker_-_Dr__Maria_Mountis: An enlarged heart can be caused by different processes. Either long standing high blood pressure, valvular disease, prior heart attacks - so to answer your question we would need more information as to what caused this. We place patients on medications such as ace inhibitors, beta blockers, to help promote remodeling of the heart. We will follow with physical exams as well as echocardiograms to assess how the heart responds to therapy.
Janerww: How long is the process for reverse remodeling after valve surgery?
Speaker_-_Dr__Maria_Mountis: It may take upwards of months to see remodeling after valve surgery. Medications should be continued during this process.
Stem Cell Therapy
jillian: Are you using stem cells treatment for heart failure? If so - what are the indications for this therapy?
Speaker_-_Dr__Maria_Mountis: We have three ongoing trials with stem cell therapy. All have various indications. Usually in patients who have had prior heart attacks. We would be happy to screen your case for enrollment into these trials.
sassy: If I have my medical records from my cardiologist can I send them to the clinic for an initial screening for a trial or do I need to come in person for the screening
Speaker_-_Dr__Maria_Mountis: It is always best to have an evaluation to determine if you are a candidate for a trial - or even approved therapies that may not be available to you locally. Sending records in advance of your appointment is always helpful.
Right Sided Heart Failure
lucky15: My husband has right side heart failure - diagnosed about 3 months ago. No one seems to know why he would have this. I am thinking we should get to the clinic for an evaluation. His symptoms are getting worse. What are the causes and treatments for right sided heart failure?
Speaker_-_Dr__Maria_Mountis: There can be multiple reasons for right sided heart failure. This may be in combination with left sided heart failure or it may be a separate medical problem. Evaluation by a heart failure specialist would be recommended - I would be happy to speak to you further. Management of right sided heart failure includes diuretics such as Lasix but without knowing what caused it would be difficult to discuss treatment with you at this time.
Janerww: Can an asthma flare-up be a causative factor in precipitating right sided heart failure?
Speaker_-_Dr__Maria_Mountis: Long standing lung disease, including COPD, emphysema can lead to right sided heart failure. An asthma attack may exacerbate it.
Supplements, Vitamins and Heart Failure
leej: What do you think about C0Q10 for heart failure? I have been diagnosed with heart failure and one of the posting boards talked about supplement such as this for your heart. What about L-carnitine - I have also heard that could help you.
Janerww: What are your thoughts on CoQ10, ribose, magnesium, L-carnitine as supports to heart muscle metabolism?
Speaker_-_Dr__Maria_Mountis: Typically these supplements are not prescribed for patients with heart failure. There is a class of patients with metabolic cardiomyopathies that may benefit from supplements but in general we do not prescribe these. Currently there are no trials that I am aware of that show long term benefit from these medications. Prior to taking any vitamins or supplements - please discuss with your doctor.
Mechanical Assist Devices (Ventricular Assist Devices – VADs)
susieq1: My brother has heart failure - he has been in and out of the hospital for several months with symptoms of shortness of breath, swelling, fatigue. His doctors don't know what else to do for him. Would he be a candidate for a mechanical assist device?
Speaker_-_Dr__Maria_Mountis: Without knowing his case in detail, it would be difficult to answer. Patients with advanced heart failure should be evaluated for advanced therapies including heart transplantation as well as mechanical assist devices. He should be evaluated by a cardiologist or heart failure specialist to ensure optimal management of his case.
Cleveland_Clinic_Host: Dr. Mountis can you tell us more about Mechanical Assist Devices?
Speaker_-_Dr__Maria_Mountis: Currently mechanical assist devices also called ventricular assist devices - or VADs - are approved by the FDA for use in patients with advanced heart failure as a bridge to transplant or destination therapy.
A bridge to transplant involves patients who are waiting for heart transplantation, a heart is not available, but they are too sick for purely medications.
Destination therapy is used for a patient who does not qualify for heart transplantation due to age, other co-morbidities. Destination therapy would mean that they would live with this device long term.
Diet and Heart Failure
sassy: what is your opinion of alcohol consumption with CHF - a glass of wine a couple of timer per week for example?
Speaker_-_Dr__Maria_Mountis: Every case varies. In some patients alcohol can be a toxin to the heart if consumed in large quantities. Please discuss with your cardiologist.
sassy: with chf should you limit caffeine or fluid intake in general - how much per day
Speaker_-_Dr__Maria_Mountis: Every case will vary - but in general we ask patients to limit fluid intake to less than 2 liters of fluid per day including all fluids such as juices, coffee, water, juices, soups, etc.
Exercise and Heart Failure
sassy: what type of exercise do you recommend for people with heart failure?
Speaker_-_Dr__Maria_Mountis: Once heart failure is well controlled I encourage patients to perform aerobic exercise including walking, treadmill, stationary bike, swimming. I discourage weight lifting. Please speak with your cardiologist prior to starting any exercise program. We have a wonderful cardiac rehabilitation program at many locations through the Cleveland Clinic which we can refer you to.
TomD: Why do you discourage weightlifting? I don't weight lift but I do some "strength exertion" such as hoisting sails. I'm a 67 yo with a 33 yo old CBGE with LIMA by Dr. Loop.
Speaker_-_Dr__Maria_Mountis: I discourage heavy weight lifting in patients with chronic heart failure because of the extra stress it puts on the heart. If your case has been stable - your doctor can tell you if heavy lifting is safe for you.
puppy21: My dad had a heart attack last week and while he was in the hospital they said his ejection fraction was 30%. Can you tell me more about what that means and if his ejection fraction can improve?
Speaker_-_Dr__Maria_Mountis: A heart attack results because of a blockage in one of the arteries of the heart which leads to lack of blood flow and oxygen. This can cause some permanent damage to the heart as well as an area of stunned or hibernating heart muscle which may improve. He should be on medications for this including ace inhibitors and beta blockers and re-evaluated over the next 3 months for improvement.
bbny404: I have a mitral valve and aortic valve leak and congestive heart failure. I have been told I am high risk for any surgery due to my heart muscle? Is that something your hospital has experience with?
Speaker_-_Dr__Maria_Mountis: Yes. We manage patients with complex medical problems and it appears that you are familiar with your case. Any time you have valvular disease with a weakened heart muscle it is considered a higher risk case. I would recommend that you be evaluated by a heart failure specialist because we may have options for you.
oldblueeyes: Typically how long do Cow / Pig valves last, and is one superior over the other?
Speaker_-_Dr__Maria_Mountis: The decision of the type of valve - bioprosthetic vs. metal - will be made between you and your heart surgeon. Typically bioprosthetic valves last 10 years and metal valves last longer but each case varies.
Cleveland_Clinic_Host: Those were all the questions we had for today, I'm sorry to say that our time with Dr. Maria Mountis is now over. Dr. Mountis, thank you again for taking the time to answer our questions about heart failure.
Speaker_-_Dr__Maria_Mountis: Thank you for having me. I truly enjoyed this and if anyone has further questions for me or any cardiologist in the heart failure section - we would be happy to see you for an appointment.
TomD: Thanks for the answer and the entire chat.
Speaker_-_Dr__Maria_Mountis: My pleasure.
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