Cleveland Clinic's Breadth of Heart Failure Therapies

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Amanda Vest, MBBS:

We’re very pleased to have the opportunity to talk to you about some of the things that are new about heart function and heart recovery. My name is Amanda Vest, the Section Head of Heart Failure and Transplant Cardiology here, and a transplant cardiologist.

Edward Soltesz, MD:

And hi, I'm Ed Soltesz. I'm one of the cardiac surgeons here. I'm the Surgical Director of the Kauffman Center for Heart Failure and Recovery, on the surgical side. Today, we'd like to share with you some of the advances in heart failure therapies that we are offering patients here at Cleveland Clinic. With over 6 million patients in the United States suffering from heart failure, this is certainly something that is on our minds and obviously on your minds as a patient. We'd like to share some of what we have to offer for our patients today. Amanda?

Amanda Vest, MBBS:

So, one of the first questions that patients often ask is, “What might cause these heart conditions that we're talking about?” There are things that can be contributors towards the condition we call heart failure.

That really means the body isn't quite being met in its needs by the blood flow going around. This can either be because the heart is weak and not able to push enough blood around, or it can be because the heart is stiff.

In that first situation, we call that heart failure with reduced ejection fraction, where the pumping function is weak. In the second situation, you'll hear that referred to as heart failure with preserved ejection fraction, where the heart is stiff. In that scenario, we mostly see heart failure with preserved ejection fraction in people as they age, with major risk factors being high blood pressure, excess weight, physical inactivity, and things like smoking, atrial fibrillation, and chronic kidney disease.

For those with weak hearts, there can be a lot of different causes. So, speak to your doctor about this. Some people have a genetic cause, meaning it's an inherited issue through their family. Others may have had a heart attack that leads to an area of weakness in the heart. For some people, that may be another medical condition. Maybe a thyroid abnormality or something like that, which sometimes can be reversible. In some cases, it's an arrhythmia of the heart that's really driving the weakness. So, it’s super important to be working with the heart specialist and figure out when a low pumping function is found, what might be the cause, and could there be anything reversible.

Edward Soltesz, MD:

Now, Amanda, we've heard a lot about some recent advances in medical therapy for heart failure. A lot of patients who have both types of heart failure can be managed reasonably well for quite awhile with medical therapy. Can you tell us a little bit about that?

Amanda Vest, MBBS:

That's right. For some years, patients with stiff hearts really had very limited treatment options. Really, we only had the water medicines, diuretics to get the fluid off.

But now, we do have one type of pill called SGLT2 inhibitors, that’s dapagliflozin, empagliflozin, which improve the body's metabolism, which help to reduce symptoms, keep people out of hospital and living longer. Some really interesting work has been coming through in the past year for those individuals who have some extra weight in the setting of having a stiff heart. There are medications that can be injected once a week that help with metabolism and can really improve breathing and help keep people out of the hospital.

Then, for our patients with weak pumping function, we talk about the four pillars of medical therapy. There are four classes of medications that have been shown over a few decades now in multiple clinical trials to help that weak and enlarged hearts to start to shape up. In many cases, they can even get back towards normal or even normal pumping strength to help keep people out of the hospital and help them live longer. These medicines, such as a group called the beta blockers that protect the heart from adrenaline, the angiotensin receptor antagonists, that group, and the mineralocorticoid antagonists, those SGLT2 inhibitors, as well, are the four groups that can be very helpful to help people feel better. So, if you're in this situation, certainly speak to your doctor and make sure all the appropriate medicines are prescribed.

Now, going beyond that for particularly people with weak pumping function, there may be other procedures, other devices for those with symptoms that are not completely improving with the medicines. Can you tell us a little bit about some of those?

Edward Soltesz, MD:

Sure, Amanda. Some patients, as Amanda had mentioned, have poor heart function because of coronary artery disease or valvular heart disease. So, oftentimes we are able to offer them conventional cardiac surgery, that is either valve repair or replacement or coronary bypass surgery, which will help improve not only their symptoms but also their survival and sometimes even return their heart function to more normal levels.

That's what we start with for some patients. But there are, of course, other patients who maybe have normal coronary arteries, and they really have a cardiomyopathy of an unknown origin, who've been treated medically for quite some time successfully, who then begin to acquire what we call more advanced therapies. Advanced therapies are particularly things like left ventricular assist device therapy or heart transplantation.

In the past, when we talked about these two, putting pumps in patients and replacing their hearts, this was really something reserved for a very small group of patients. But now we've really come to a revolution in this technology. We have a lot more hearts available for patients for transplantation. We also have an amazing pump now, the HeartMate 3 left ventricular assist device pump, which is offering patients improved survival and significantly improved quality of life compared to previous generations of pumps. This is not something that used to exist years ago. This is very new technology, and many, many people are taking advantage of this.

Amanda, can you talk a little bit about who you would feel is a good candidate for one of these advanced therapies?

Amanda Vest, MBBS:

Absolutely. So, with every patient with a weak pumping function, we’re firstly thinking about the medications that you've had, lifestyle measures that may include what we can do with exercise and with dietary approaches. For those who are still having heart failure hospitalizations, are still having a lot of symptoms and limitation in their life, then we may be going through some of those intermediate measures. Sometimes also, either invasive or noninvasive devices to monitor the patient at home and to be able to tweak those medicines more precisely to get them feeling better.

But for patients who are still having a lot of shortness of breath, maybe having a lot of issues with fluid retention on the body, those individuals who have had more than one hospitalization in a year, and especially patients who have been very sick and in our intensive care units, perhaps where the kidneys or the liver are not getting enough blood flow, those are really high risk situations. In those scenarios, the care team is talking to patients about how, unfortunately with the best of efforts, those medicines and other, less invasive devices may not be doing enough, may not be giving the patient the quality of life that they're looking for. It may not be enough to keep them alive for a long enough period of time.

Those are the scenarios where we're starting to talk to patients about whether either heart transplantation or the left ventricular assist device heart pump might be the next step to achieve those goals of feeling better, staying out of the hospital and living longer. Here at Cleveland Clinic, we are so fortunate to have a wonderful multidisciplinary team who helps patients and families all the way through that spectrum of lifestyle, medication, device and transplantation options. Would you like to speak a little to that team?

Edward Soltesz, MD:

Sure, Amanda. Amanda spoke just recently about a care team, and that truly is what it is. A multidisciplinary care team composed of cardiologists, cardiac surgeons, social workers, nurse practitioners, physician assistants, a whole group of caregivers who are focused on making the best experience and the best outcome for each individual patient.

I think what really sets us apart here at the Cleveland Clinic is the tremendous depth of experience that we have and the true multidisciplinary nature of our practice. We truly do individualize each patient's care, looking at not only medication management, but device management, lifestyle management, nutritional management. We bring all that together, and we really are able to offer the patient a focused approach that truly is precision medicine in the 21st century. I think that's really what sets us apart at the Cleveland Clinic, and really what you will see as a patient here.

Amanda, one of the other things that we have a lot of are trials, opportunities for patients. Can you maybe speak a bit about that?

Amanda Vest, MBBS:

That's right. We have a wide variety of trials, really across the spectrum of those interventions that you've talked about. A clinical trial can be appropriate for a patient who's doing quite well. Or they may be appropriate for a patient who maybe isn't doing so well and has been seen perhaps in other hospitals and where there don't seem to be so many options. For example, we have trials all the way through nutritional interventions, through some new medications coming in.

For example, there's an international trial starting up shortly of a medication called Omecamtiv that we’ll be a part of here, which is a medicine for people with quite low pumping functions indeed, to see if on top of those four pillars of therapy, can any additional squeeze of the heart help patients to stabilize?

We have a number of devices in study at the current time, which is quite an exciting area. Various devices that may help the pressures and flows in the heart do better, or to hold the structure of the heart in a better way. As well as also, even a device trial coming in that's a new left ventricular assist pump, that has used new technology to bring forward an alternate option for those patients with the most severe heart failure. So quite a wide variety of options across the spectrum here.

Edward Soltesz, MD:

Amanda, if you had one thing to say to our listeners today, as we conclude here, what piece of advice would you give them?

Amanda Vest, MBBS:

I think the advice is on both ends of the spectrum. The first piece of advice is for anybody who thinks that they may be having difficulties with heart failure. That would be anybody having symptoms like shortness of breath, fatigue and intolerance of their activities or filling up with fluid. It’s so important to connect with your health care professionals quickly because, as you've heard, there's really a wide variety of treatments that we have in the modern era that can help people in that situation.

And then, for people a little bit more advanced with that condition, maybe they've sought help elsewhere and maybe they're still not doing so well. We do have a number of opportunities, both in terms of regular clinical care across our care team, as well as clinical trials that could help somebody who has been suffering from this heart failure condition without adequate treatment. We'd love to meet any patients across that spectrum.

Edward Soltesz, MD:

I think the key message here that you're hearing is that we can offer you a second opinion, if you'd like. We're here for you. We're one phone call away. So, give us a call.

Amanda Vest, MBBS:

For more information on heart failure treatment at Cleveland Clinic, please visit clevelandclinic.org/heartfailure. That's clevelandclinic.org/heartfailure. You can also make an appointment by calling 844.868.4339. That's 844.868.4339. Thank you for listening to Love Your Heart.

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