Caitlin Whyte (Host): When the heart can't pump enough blood to meet the body's needs, this is considered heart failure. And today we are talking about defining congestive heart failure and advanced heart failure treatment options with Dr. Baqir Lakhani, an Advanced Heart Failure and Transplant Cardiologist.

This is “Health Cast” from Ascension Illinois - I'm your host, Caitlin Whyte. Doctor, just to start off our conversation, tell us what heart failure is and how it's diagnosed.

Baqir Lakhani, DO (Guest): So, heart failure is the inability of the heart to meet the demands of the body, which basically results in symptoms for any patient like shortness of breath, tiredness, or fatigue, palpitations, or the inability to do just normal day activities.

There's two types, diastolic, which is most commonly associated with hypertension and systolic, which is most commonly associated with blocked arteries or coronary artery disease. In diastolic, you don't have a weakening of the heart, your ejection fraction, or your pump function is normal. And systolic, your pump function actually goes down. So, normal is about 50 to 55%. And in systolic, yours would be lower. When we talk about heart failure, we're mainly talking about the left side of the heart. So, that's important to remember. And the diagnosis is mainly through an echocardiogram, which a cardiologist will order. That is basically an ultrasound of the heart to look at the heart muscle and its intrinsic pump function and any kind of other problems that they may see while they're doing the ultrasound of the heart, such as valve disease or a wall of the heart that's not moving properly. That clues the cardiologist into what is wrong with the heart and what is the underlying cause. They may also order other tests like a stress test or labs.

That is all just to figure out what the underlying cause is, because once we figure out that the heart is weak or stiff, as we refer to it, or as I refer to it in diastolic dysfunction, then we got to figure out why it is the way it is.

Host: Now, is heart failure hereditary? And then are there any modifiable risk factors to help prevent the condition?

Dr. Lakhani: In some cases, heart failure is hereditary. There are known genes and genetic mutations that cause heart failure and those seem to run in families. So, don't ever be surprised if you're being asked about your grandparents, your parents, your children, because we look for three generations of information to figure out if it's truly kind of a quote unquote, hereditary or genetic cause, and they may run lab testing to figure out.

Both sides, of course. You got to remember both that you have a mom and a dad, so they ask about both. Besides being genetic or besides being hereditary, there are other conditions that can lead you or put you at increased risk for heart failure. So, things like obesity or being overweight, or having other medical history that you should control, like high blood pressure, sleep apnea or diabetes, trying to stay away from excessive use of alcohol. Not smoking. And then just basic things like diet and exercise. So, those are definitely modifiable for any person and should be while you are diagnosed with those conditions, if you do have them, to make sure that you don't ever have to encounter the diagnosis of heart failure.

Host: At what point does heart failure become advanced then?

Dr. Lakhani: Patients that have heart failure are of two kinds. Sometimes you get diagnosed with heart failure and I will say heart failure is more heart dysfunction. Heart failure makes it sound really dreadful, but it's more dysfunction at the beginning. But when you have a patient that for instance has blocked arteries and has a weak heart, which is that percentage of less than 50% or 40% technically, they can live with that heart dysfunction as long as they take their medications, for decades. But at some point the underlying heart dysfunction can progress. And then that's when you are diagnosed with advanced heart failure. The other thing is that sometimes you develop heart dysfunction because of an acute cause such as COVID.

That has been a recent kind of discovery with this pandemic over the years. And so sometimes, when you have that dysfunction, that may not recover and you kind of progress really rapidly into advanced heart failure. And so advanced heart failure is defined by certain terms. So you have, because of your heart, you're just always fatigued, always symptomatic, your kidney function or your liver function is not well, because of your heart, you're just always retaining fluid or you're not getting the blood to the heart. You keep on having hospitalizations for heart failure, mainly looking for more than about two or more in a year. And then sometimes it presents with low blood pressure or the inability for a person to take his heart failure medication as he, he or she usually would. That's when it becomes advanced.

Host: Gotcha. Okay. So, then tell us the difference between treatment options for heart failure and that advanced heart failure.

Dr. Lakhani: So, heart failure is actually easy, right? There are many different medications that can be taken and although people don't like taking medications. What I tell my patients is you let me worry about the medications and just take them and I'll worry about everything else. And you worry about your life and living it to the fullest potential. From a stiff heart failure, diastolic heart failure standpoint, there are one or two medications. Spironalactone is one of them that has been around for a while. And then the newest ones are Farxiga and Jardiance. And those are newer medications that have been shown to help in diastolic heart failure. Systolic heart failure, we have a ton of therapies and just to go over the main ones; we have four main medications that we talk about. It's metoprolol or some metoprolol succinate, which is something in that family which are known as beta blockers, angiotensin receptor, neprilysin inhibitors, which is a big word for Entresto, which people may have seen the commercials on, spironolactone again. And then Farxiga again.

So, these are common medications that we do use in systolic heart failure that do five things and knowing the importance of the medications is why I would want, as a physician for a patient to take it and why a patient should take it. So, these medications do four or five main things. One, they try to help you help the patient increase that ejection fraction, keep you from having the symptoms, keeping you from having hospitalizations for heart failure. Keep you from having side effects of heart failure, like bad arrhythmias and the fifth one, and the most important one is increasing your survival even if you have a weak heart. So, these medications are very important. And then people that do have a weak heart, the one thing that they will note is that sometimes the cardiologist will recommend a device or an ICD. That is when your ejection fraction or your pump function is low enough and we worry about arrhythmias associated with heart failure.

So, that's just for heart failure or heart dysfunction. For advanced heart failure, we talk about three or four main things. Depending on the age of the patient, their other medical history and their health at that time. The top of the list is heart transplant. Of course, being evaluated for a heart transplant. Sometimes a patient's heart are so dysfunctional that they can not be considered for anything else. And they are at that point, healthy enough to be considered for a heart transplant. Of course, you have to be a candidate for these. Then there's something called an LVAD. It's a left ventricular assist device.

It's basically a metallic pump that goes into the heart via cardiothoracic surgery. It's a pump that takes the job of the heart. Third is IV medications that you go home with, which we call inotropes. So, these basically make the weak heart beat stronger and faster at times to give the patient the ability to do their activities at whatever level they can.

And then the last one, which is somewhat scary to people, but, you know, I think is an important discussion to have when you have a weak heart is, you know, sometimes you have a weak heart and there's a lot of medical conditions and the risks of these big procedures, like heart transplant and a heart pump really outweigh the benefits of going through them.

And so we talk about palliative care. We talk about goals of care, and we talked about, and for some patients, end of life care and what that looks like for them. And those are not conversations to be afraid of, but just to be open-minded about to make sure that all options are considered and exhausted before we have those conversations.

Host: Absolutely. Well, I'd love to loop around and talk more about that VAD technology. Just what is it?

Dr. Lakhani: An LVAD is a left ventricular assist device. It's basically a mechanical pump. It's a metallic pump. The size, it can basically, it can sit in your palm. That's how small it is and via cardiothoracic surgery, it's implanted into the left side of the heart. It basically takes the blood from the left side of the heart and puts it into the main artery of the heart, which is the ascending aorta, which then provides blood to the rest of the body.

So, it takes the job of the heart. It's implanted surgically, and then there's conditions that come with it. Of course, a metallic pump doesn't run on its own. So, there's a power line that comes out of your abdomen from this pump. There's batteries that have to be charged. You have to be on the blood thinners. But these are all kind of the things that we explain to our patients when they are a candidate for an LVAD or a V-A-D VAD.

Host: And how has this specific technology improved over the years? And where do you see the trend taking us in the future?

Dr. Lakhani: So, the technology has definitely improved over the years. The first LVAD was successfully implanted in 1966, but the machine itself was probably the size of a cabinet. The pump itself was in the abdomen because it was so big and it was pneumatically or run by kind of air. And so from that time till now, it has improved to the point where it is interthoracic. So, only in your chest. It is electrical and you only need to worry about batteries that are the size of maybe a mug or so maybe just a little bigger.

And the complications at that time, that first successful LVAD patient didn't make it out of the hospital. They didn't get to leave the hospital. Whereas our LVAD patients now, get to live their own lives, go out of the hospital, go back to work, go back to hiking, exercising, doing whatever they need to do that gives them a great quality of life.

So, it's definitely improved over the years. It is going to get more common as we go forward. And the reason for that is that heart transplant for these patients that have a dysfunctional heart, a weak heart, a failing heart, you know, the ultimate goal for every patient as an advanced heart failure cardiologist, is heart transplant, but there's always reasons or conditions or other history that comes up that we, that not everybody is a transplant candidate. And then there's a limited number of transplant donors, heart transplant donors, but there are a plethora of patients that have a failing heart. And so to make sure that everybody gets treatment and the ability to live their lives the way they want and get a full functional life, we're seeing this increase. And I think we're only going to see this go forward and get more common as the technology gets better. And as we continue to have a shortage of heart transplant donors.

Host: Well, Doctor, wrapping up here, any last words, any other thoughts that we didn't touch on?

Dr. Lakhani: I think the one thing that patients or persons have to remember is that when you're diagnosed with heart dysfunction or more commonly known as congestive heart failure, that it is not the end of the road. Some people stop exercising. Some people stop going out with their family because they think life is over. And that's definitely not the case. Not in current medicine. We have ways to treat them, to give them their life back. And it shouldn't be a diagnosis that we should be scared of, but more so a diagnosis, when we hear it, we should seek treatment with an appropriate physician and probably seek help through a cardiologist to make sure that their quality of life is fulfilled, even with that diagnosis.

Host: Well, we so appreciate your time, Doctor, and the access to this vital information. To learn more, visit us online at ascension.org/ILheartfailure [Ascension dot org slash I-L heart failure]. I’m Caitlin Whyte and this is “Health Cast” from Ascension Illinois.