Quick Questions: Heart Failure

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. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations, and more. Enjoy.

Amanda Vest, MBBS:

Welcome everyone, and thank you so much for joining. To kick things off, I'm Amanda Vest, a cardiologist at Cleveland Clinic. I've been practicing as a cardiologist for about 12 years. I see patients at the main campus in Cleveland at the Kaufman Center for Heart Failure Treatment and Recovery. My specialty area is around heart function, heart pumps and heart transplantation.

How do you know if you have heart failure? Are there any tests that cardiologists would order to help identify such a diagnosis? Well, the most common symptoms that people would experience from heart failure are shortness of breath, fluid congestion and fatigue.

To go through those, the shortness of breath or tightness in the chest is generally first noticed when somebody is walking around or can be noticed when lying back in bed. For example, getting short of breath and needing to prop yourself up with pillows in the night. Now, this usually relates to fluid that is backing up from the heart towards the lungs. That fluid can also back up in other places in the body. People might notice their belly swelling or see their ankles or feet getting puffy, or may notice their weight suddenly jumping up very quickly on the scales, like five pounds in a week, which is a giveaway sign that it's probably fluid coming on the body. Then, with the fatigue, that may really slow people down and prevent them from doing the things that they can normally do physically.

Most clinicians would, if suspecting heart failure, reach for a couple of tests first. One blood test that can be very helpful is something called the BNP, the B-natriuretic peptide, or there's a version that's most commonly used called the NT-proBNP. It's a bit of a mouthful, but it basically means a blood test that helps us to understand if there's stretch on the heart and salt or water hormones being activated in the body. That blood test, the NT-proBNP can be quite helpful.

Then another test often ordered is the echocardiogram, which is that ultrasound of the heart, when the technician puts some cold jelly on the chest and gets some pictures on the chest wall of the heart beating underneath with an echo machine. That helps us to tell if there is an issue with heart squeeze or perhaps heart stiffness, or maybe with the valves.

Other tests that could be ordered early on is that electrocardiogram, which is the sticky dots on the chest to see the heart rhythm. Perhaps atrial fibrillation could be present as well. It may be necessary to take a picture of the lungs, called a chest X-ray, to look for water in the lungs. Sometimes, even early on, doctors may be doing things to check out the coronaries, which are the blood vessels that supply blood to the heart, or get other pictures of the heart, such as an MRI, a magnetic resonance imaging scan. Those are the early tests that may be required when somebody has a possible heart failure diagnosis or a new diagnosis of heart failure.

What is the best thing to do when you first get a diagnosis of heart failure? So, taking off where we just got to with a new diagnosis of heart failure, I would say one of the first things to do is to make sure you understand what type of heart function issue is going on here. Very broadly, we break it down into two areas. One type of heart failure is when the heart is weak in it's squeezing. You would know this because that echocardiogram, the ultrasound of the heart, gives a number called ejection fraction, which is how much blood is pumped out of the heart with each beat. That should be 55% to 65%. That's how much blood should get pushed out with each heartbeat. If it's below that, and especially if it's below 40%, that's a weak heartbeat.

There's the other group of patients who actually have an excellent squeeze. They have a normal ejection fraction, and yet they're still getting that same set of symptoms I was talking about, shortness of breath, fluid backing up, fatigue. That's because they have some issues, usually with the stiffness of the heart, that the heart doesn't relax so well. We call that heart failure with preserved ejection fraction, meaning the heart squeezes well with an ejection fraction of 50% or more, but it seems to not relax so well. Then there are some folks in the middle, with a heart squeeze of about 40-something percent. Now, it is important to know which of these categories you're in because it's going to drive a little bit of what medications are available.

Then the next thing I would say is make sure that you're writing out your answers and taking those to your clinicians and spending the time with them to understand what it is that's going on with your heart. Don't be afraid to ask questions. Especially, don't be afraid to ask questions if you don't quite understand why they're recommending one thing or another.

They will probably be recommending to you some medications. These could be diuretics. That means water medicines that make you urinate and get fluid off the body. A diuretic medicine like furosemide or torsemide is usually going to be recommended if one of those symptoms was that you're holding onto a lot of fluids and having shortness of breath or swelling.

Then there'll be additional medications recommended to try and help heal the heart. We'll talk about them a little bit more in a moment, but those medicines are really going to be a little different if one has a weak heart versus if you have more of the stiff heart condition. We'll also touch on diet and exercise in a moment, but you may get some recommendations around healthy eating and physical activity. Make sure that you ask your team why they're recommending these things, that you come away with a good idea of the initial recommendations from your heart team.

What is the best way to rebuild the heart after a heart failure diagnosis? I'm going to take up where we just left off. We were talking about weak pumping function of the heart. This is called heart failure with reduced ejection fraction, or sometimes you may hear the term systolic heart failure. Really, our best tools for strengthening up the heart in this situation are a series of medications. You may hear your clinician talk about GDMT, guideline-directed medical therapy. This essentially means four main groups of medications that have been shown over many years in a series of big clinical trials to help improve the pumping function of the heart, help people feel better, help people stay out of hospital more, and help them live longer as well. One of each of these four classes of medication is usually recommended, because together they're our most powerful tool for strengthening up the heart.

Very briefly, these medications are, one type of medication called a beta blocker that blocks adrenaline from getting to the heart and protects it in that way, slows down the heart rate. Another type of medication that improves the metabolism of the heart, called either dapagliflozin or empagliflozin. A type of medication that slightly lowers the blood pressure and blocks some of the hormones in the body that can cause the heart to get weaker and worse, and these are medications such as losartan or lisinopril or one called sacubitril/valsartan, which is two medicines together as one, marketed as Entresto. Then a type of medicine such as spironolactone, which blocks a very specific salt and water retention hormone, and again, can stop the heart from getting weaker, help improve the function, help people to do better.

You'll hear about those medications, and usually our goal is to try very hard to get people onto all four of those medicines if possible. Now, sometimes there may be kidney function reasons or low blood pressure reasons that we're unable to get somebody onto all of those medicines, but that's the goal. The better we can do with those medicines, the more likelihood of strengthening up that heart. In fact, in this modern era, when we start medicines for a weak heart, about a third of people actually have improvement of their pumping function back to the normal range and feel a lot better and do really well. Another third of people have some partial improvement and hopefully feel better.

About a third of people may not see quite so much improvement, and so in that group of people, there are also some devices, a couple of devices these days, that can make the heartbeat stronger, that look like little pacemaker devices, or even an actual pacemaker called cardiac resynchronization pacemakers. Then for those who are really in a tough spot, we have some of those heart pumps called left ventricular assist devices or even heart transplant. But the majority of patients can get better pumping function, feel better, stay out of hospital and live longer through the medications.

What are the best lifestyle practices for addressing the different types of heart failure? We talked a bit about medicines a moment ago, but let's talk a bit more about nutrition and physical activity. In terms of nutrition, particularly for people who tend to hold onto a lot of fluid and have swelling with their heart function issues, in that situation, it can be quite helpful to keep salt intake low. Salt, or sodium, as it's also known, does cause water to be retained in the body. For example, if we eat very salty foods, that can be fast foods, processed meats, soups or canned goods with lots of preservative salt in them, it can cause fluid to stick on the body, make the swelling worse, make the breathing worse.

Having said that, I think these days, some heart failure clinicians are moving away from very rigid guidelines about salt intake, and will help you think a little bit more overall about just eating fresh. Really, if you're able to eat fresh and as much as possible focus on the healthy grains, the healthy vegetables, fruits, eating meat that is not very processed and salty, so staying away from the takeouts and the deli meats, getting some of those nice Mediterranean foods, some good, healthy olive oils or avocado oils, things like that, then that's going to be a really good diet for the heart, whether one has heart failure or even whether you're trying to prevent cardiac conditions. Sometimes you may be given a number to try and keep under on the salt intake. For example, you may be told to try and limit it under 2,000 milligrams a day, but big picture, trying to eat fresh and fuel your body with high-quality foods is a great step forward.

With regards to physical activity, obviously, always check with your doctor if you have a cardiac condition, particularly if you're having symptoms when you exert yourself. But for many patients with heart failure, especially those with the low pumping function issues, cardiac rehabilitation can be a very important part of your treatment plan. Do ask your team about that. For example, at Cleveland Clinic, at many of our locations we have cardiac rehabilitation gyms where you can go work with a team there three times a week, for example, and do exercises that particularly promote heart health. You're monitored, and people are checking your blood pressure and heart rate, so it can be a really nice way to build up your activities and your confidence.

In general, I tell patients with heart failure, when I'm encouraging them to keep physically active, that it's okay to get a tiny bit out of breath, but you should still be able to speak a full sentence. If you're… having to… pause between… each word like that, you've probably done too much. You need to rest, bring it back a notch. But being able to speak a full sentence is a good place to still be able to aim to. Of course, if you're getting dizzy or having chest pressure or pain, then you need to rest and speak to your doctor about that. Other lifestyle things that are important, really across the board with heart conditions are keeping stress to a minimum, stopping smoking if one is smoking, avoiding stimulants, particularly illicit substances or other stimulating medications, minimizing alcohol. Really just trying to think about keeping an active life is super important, avoiding all that sedentary time.

Now, we didn't particularly talk about how to treat heart failure with preserved ejection fraction. That's the stiff heart condition. There, this is very much tied up in some of the metabolic issues that we can be affected by, especially as we age, things like diabetes, extra weight, high blood pressure. With heart failure with preserved ejection fraction, it becomes particularly important to be doing the physical activity, to be bringing weight back down to the normal range if it's above that. Many of the lifestyle features are key to those management plans. Although, also for patients with heart failure with preserved ejection fraction, those metabolic pills I mentioned, dapagliflozin and empagliflozin, have been shown to be effective. More recently, even the injectable medications that are used for weight management, such as semaglutide and tirzepatide, have also shown to be particularly beneficial for helping people with that stiff heart condition in the setting of also having extra weight. So, do speak to your doctor about that too.

Thank you.

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