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Heart Failure Facts
Dr. Leslie W. Miller shares important heart failure facts everyone should know. Learn more about BayCare’s heart and vascular services.
Featured Speaker:
Dr. Miller graduated from the University of Missouri, Columbia Medical School in 1974, completing his medical residency at Washington University and Barnes Hospital in St. Louis. His cardiology fellowship was completed at Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Miller is currently Director of the Heart Failure Clinic for BayCare Health System.
Learn more about Leslie Miller, MD
Leslie W. Miller, MD
Dr. Miller is board-certified in both cardiology and internal medicine (ABIM). Dr. Miller has also served as President of the International Society for Heart and Lung Transplantation and the American Society of Transplantation, as well as a Fellow of the American College of Cardiology and the American Heart Association. As an investigator in more than 80 clinical trials, his widely published research focuses on innovative heart failure treatments, including the use of adult stem cell therapy in the treatment of patients with cardiovascular disease and heart failure.Dr. Miller graduated from the University of Missouri, Columbia Medical School in 1974, completing his medical residency at Washington University and Barnes Hospital in St. Louis. His cardiology fellowship was completed at Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Miller is currently Director of the Heart Failure Clinic for BayCare Health System.
Learn more about Leslie Miller, MD
Transcription:
Heart Failure Facts
Melanie Cole, MS (Host): You’ve heard the word heart failure. I know I've heard that word. But do you really know what it is and how it differs from something like a heart attack? My guest today is Dr. Leslie Miller. He’s board certified in both cardiology and internal medicine, and he directs the heart function clinic at Morton Plant Hospital, part of BayCare Health System. Dr. Miller, first tell us what is heart failure, and how does it differ from a heart attack?
Leslie W. Miller, MD (Guest): It’s an interesting term that has been used in the past as congestive heart failure. It has evolved to the term of heart failure because some people express in a different form than congestion with having peripheral edema, but don’t necessarily have congestion. That’s really how it’s evolved to the current term. There are a couple of important statistics I think I’d like to make sure I acquaint your audience to begin with. That is it is the fastest growing form of cardiovascular disease in the world. In the United States, it is an incredibly important condition because projections from the American Heart Association suggest that it will increase by 46% by 2025, which will effect somewhere between 8 and 10 million people in the United States.
The important demographics about this condition are that men and women are affected equally. Although, it has a somewhat different evolution is that men predominate until the age of about 70 to 75, and then women live longer and have more commonly heart failure than men. When you look in aggregate, it affects both sexes about equally.
It is a condition that is age related in that it increases with age. Part of that is one of the most important differentiators of causes of heart failure is we break it into two different types. One of which is that the heart contracts normally called preserved ejection fraction type heart failure, or it is reduced. The reduced form is probably most commonly due to a heart attack, and it impairs the heart’s pumping function. We understand that the heart has two basic mechanisms of action. That includes the contraction or pumping of the heart or relaxation. Which sounds not very important, but it has become at least half of all patients with heart failure have this stiffness of the heart and blood vessels that exactly mimic the presentation of heart failure of those who’ve had a heart attack or have reduced heart function from other causes.
So it’s important that we differentiate those two types because the management is somewhat different. Unfortunately, we find that regardless of the type of heart failure, it has a significant reduction in both quality of life and survival. Estimates now range approximately 50% of people will, unfortunately, not survive more than five years from the diagnosis of heart failure. When we find it in a more advanced phase, it’s even more reduced. So it’s a diagnosis that’s very important to establish, very important to get on guideline dosing of medicines that have been proven to be beneficial for treating people with heart failure, and to be followed fairly closely to make sure that they optimize their medications.
Host: That was a great explanation. Dr. Miller, that was excellent. What a great educator. Now, can you tell us some of the symptoms? Would someone know? Fatigue, would they feel it? How would they know that they have impending heart failure?
Dr. Miller: It’s a great question and one of the most important things for people because sometimes it mimics. We see patients who commonly are thought to have asthma or underlying lung disease that is causing their very typical increasing shortness of breath when they exert themselves. When it progresses a little more, they may wake up at night feeling breathless or wake up at night with a cough. That represents fluid that has accumulated in the tissues during the day. When you're at rest at night, they come back into the circulation in a fairly rapid manor and congest the heart. That congestion is secondarily extended up in the lungs and it causes this cough at night or awakening short of breath. Those are the two most common symptoms that we see.
People may also find that they have swelling in their feet and ankles. Their shoes don’t fit the same. Others may describe that their hands are tight. That they're picking up extra salt and water or fluid, which we refer to as edema. Those are probably the most common manifestations of heart failure regardless of whether it’s the preserved or reduced function types.
Host: Then let’s speak about some of the treatments. But before we do, how do you diagnose it?
Dr. Miller: Really an important question. The very most recommended diagnostic tool is the echocardiogram. It’s very simple and well tolerated. It places a probe on the chest wall, and it allows imaging of the heart to completely—It’s rather astounding. It’s like sonograms that you can really visualize all the chambers of the heart, the thickness of the walls, and most importantly how well it contracts and whether it effects both the left side of the heart and the right side of the heart. It is the national guideline first diagnostic test of someone that we think might have heart failure is to get an echocardiogram. Easy to obtain and it takes about 20 or 30 minutes and can be obtained in any hospital or large clinic treating patients with heart failure.
It gets more advanced. If we think that there’s a question that patients might have ischemic heart disease or coronary narrowing that has either been the cause of their heart failure or may be causing dysfunction at the time, they may require a cardiac catherization where we actually can inject dye into the coronary arteries and prove that that’s not there. They may have a measurement of the pressures in their heart and lungs. The number one diagnosis that really should suffice in most patients to unequivocally establish a diagnosis is the echocardiogram.
Host: Is this considered a chronic condition now? As you mentioned five years out depending on when it’s found or your age and other comorbidities. Do you look at this as something now, Dr. Miller, that is managed as opposed to cured or treated in some way?
Dr. Miller: It’s a really important question. Unfortunately, I’d have to say that’s it’s a management. I think with really more aggressive and attentive care, we can hopefully extend this. It is a progressive disease. Like many other chronic diseases, it has variable progression. So that not everyone, those are averages. So other people may well get under good medical management and survive for 10 years, and others may find progression, unfortunately, that becomes more symptomatic and limiting in a shorter period of time.
Host: What about diet? You mentioned that they could have swelling in their legs and feet. Tell us where diet and salt and the things that we eat can contribute to or help with heart failure.
Dr. Miller: That’s really the starting point, and we’ll talk in a minute about the advances in medical therapy and oral drugs that can help really improve the symptoms and the function of the heart. But we really start with salt and water ingestion. Salt has the pension for causing a retention of fluid in the body. We see people who may be salt advocates and enjoy eating salt with many of their meals, but when we find patients with any form of heart failure, we try to reduce that. I don’t think it needs to be draconian, but in general we ask that they not cook with salt or add salt at the table and use salt substitutes.
We address that very much in the first several office visits when we initially begin helping to manage a patient with heart failure, but we also talk about fluid ingestion. Many of these people need a so called diuretic or a pill that will help clear salt and water and fluid in the body. We find that patients get thirsty and so they go back and they're drinking a substantial amount of fluid. So salt sets you up to hold onto fluid, but if you take an excessive amount of fluid, that will always lead to an increase in edema and swelling. So we absolutely start with trying to manage salt and water intake.
Then we progress to what are national American Heart Association guidelines of medications. We try not to get into polypharmacy or using multiple medications, but we do find that heart failure is a symptom of a broad compensatory response of the body to reduce function or impaired function. All of those are different mechanisms. Therefore, we end up quite often using two or three different types of drugs, but it is an algorithm or a progression of adding medicines based on response or lack of response in patients. As I mentioned before, the diuretics are the first line of therapy in most patients, but we try to never use a diuretic as monotherapy, as just that. Because it causes electrolyte depletion and it really doesn’t change the heart’s pumping function. It simply manages symptoms.
The current guidelines now include, as the first line drug, is a relatively new drug that you’ll see in television commercials called Entresto. It’s because this has been tested in an 8,000 patient international trial and found to be the most effective at improving heart function, reducing hospitalizations, and improving survival over what we had before. So that is, in those patients with reduce systolic function type of heart failure, about half the population. The second line, or would be used in patients with preserved function, may be a so called ACE inhibitor, like lisinopril. Or it could be other drugs because the most common coexisting problem, if not cause of the patients who are typically older and have preserve pumping function, but impaired relaxation is that they have high blood pressure. The patients with reduced heart function more typically have low blood pressure. So it’s somewhat easier to treat patients with the higher blood pressure type of impaired heart function because it opens up a number of options.
But a second drug that is very commonly used and prescribed is the class of drugs called beta blockers. That may be agents, specifically metoprolol or carvedilol or sotalol. They all end in an ‘ol’. These are drugs that really block the body’s sympathetic response, which means it increase their resistance, it increases their heart rate. Again, just a wealth of data in international trials proving that these drugs have a very important benefit in improving heart function, but also reducing mortality. So we really see--One of the things that I spent a lot of time with is that physicians have understood the need for these drugs, but they, unfortunately, don’t get to guideline dosing. So it’s really important if a patient is diagnosed with heart failure that one, they're on the right drugs. But secondly, that they're on the right doses. We work with patients to try and titrate them to get to what the studies have shown is the best dose. So it’s an important part of their management is good medical therapy and try to make it as simple as we can depending on the severity of their symptoms.
Host: Dr. Miller, looking forward to the next 10 years in the field, where do you see heart failure research going? What’s exciting that we might want to know about on the horizon? Please wrap it up for us. Give us your best advice about preventing heart failure, recognizing those symptoms, and getting in for our well visits and to see our doctors when we think there’s something going on.
Dr. Miller: Sure. There’s a lot of new things coming, but I think that we’re really aware of how rapidly this condition is progressing. And that it’s really going to become even more focused on patients with advanced stage and preserved heart function. So I think in patients who developed increasing shortness of breath when they exercise or find themselves with puffiness in their feet or ankles or difficulty breathing that they should see someone, a physician, ideally a cardiologist to help make this diagnosis and get on the right medicines. There are just a host of new medications coming. We have clinical trials now with a couple of new investigative drugs. But we’re also working with new advances including stem cells and genes as we understand more about the mechanisms of heart dysfunction and we’re able to alter it with these new research trials. So encourage people to keep that as a potential part of their future.
I want to finish with perhaps the most important part, and that is prevention. That is weight control, blood pressure control, and exercise. All of these factors can limit this. Diabetes is one of the fastest growing causes of heart failure. High blood pressure is an important cause of that. Atherosclerosis and ischemic heart disease. So pay attention to diet, exercise, smoking cessation are all the most important preventions to prevent the development of heart failure.
Host: Thank you so much, Dr. Miller, for coming on with such great information about the prevalence and the things that people can do to hopefully prevent it in the first place. Thank you, again, for joining us. You're listening to BayCare Health chat. For more information, please visit baycare.org. That’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.
Heart Failure Facts
Melanie Cole, MS (Host): You’ve heard the word heart failure. I know I've heard that word. But do you really know what it is and how it differs from something like a heart attack? My guest today is Dr. Leslie Miller. He’s board certified in both cardiology and internal medicine, and he directs the heart function clinic at Morton Plant Hospital, part of BayCare Health System. Dr. Miller, first tell us what is heart failure, and how does it differ from a heart attack?
Leslie W. Miller, MD (Guest): It’s an interesting term that has been used in the past as congestive heart failure. It has evolved to the term of heart failure because some people express in a different form than congestion with having peripheral edema, but don’t necessarily have congestion. That’s really how it’s evolved to the current term. There are a couple of important statistics I think I’d like to make sure I acquaint your audience to begin with. That is it is the fastest growing form of cardiovascular disease in the world. In the United States, it is an incredibly important condition because projections from the American Heart Association suggest that it will increase by 46% by 2025, which will effect somewhere between 8 and 10 million people in the United States.
The important demographics about this condition are that men and women are affected equally. Although, it has a somewhat different evolution is that men predominate until the age of about 70 to 75, and then women live longer and have more commonly heart failure than men. When you look in aggregate, it affects both sexes about equally.
It is a condition that is age related in that it increases with age. Part of that is one of the most important differentiators of causes of heart failure is we break it into two different types. One of which is that the heart contracts normally called preserved ejection fraction type heart failure, or it is reduced. The reduced form is probably most commonly due to a heart attack, and it impairs the heart’s pumping function. We understand that the heart has two basic mechanisms of action. That includes the contraction or pumping of the heart or relaxation. Which sounds not very important, but it has become at least half of all patients with heart failure have this stiffness of the heart and blood vessels that exactly mimic the presentation of heart failure of those who’ve had a heart attack or have reduced heart function from other causes.
So it’s important that we differentiate those two types because the management is somewhat different. Unfortunately, we find that regardless of the type of heart failure, it has a significant reduction in both quality of life and survival. Estimates now range approximately 50% of people will, unfortunately, not survive more than five years from the diagnosis of heart failure. When we find it in a more advanced phase, it’s even more reduced. So it’s a diagnosis that’s very important to establish, very important to get on guideline dosing of medicines that have been proven to be beneficial for treating people with heart failure, and to be followed fairly closely to make sure that they optimize their medications.
Host: That was a great explanation. Dr. Miller, that was excellent. What a great educator. Now, can you tell us some of the symptoms? Would someone know? Fatigue, would they feel it? How would they know that they have impending heart failure?
Dr. Miller: It’s a great question and one of the most important things for people because sometimes it mimics. We see patients who commonly are thought to have asthma or underlying lung disease that is causing their very typical increasing shortness of breath when they exert themselves. When it progresses a little more, they may wake up at night feeling breathless or wake up at night with a cough. That represents fluid that has accumulated in the tissues during the day. When you're at rest at night, they come back into the circulation in a fairly rapid manor and congest the heart. That congestion is secondarily extended up in the lungs and it causes this cough at night or awakening short of breath. Those are the two most common symptoms that we see.
People may also find that they have swelling in their feet and ankles. Their shoes don’t fit the same. Others may describe that their hands are tight. That they're picking up extra salt and water or fluid, which we refer to as edema. Those are probably the most common manifestations of heart failure regardless of whether it’s the preserved or reduced function types.
Host: Then let’s speak about some of the treatments. But before we do, how do you diagnose it?
Dr. Miller: Really an important question. The very most recommended diagnostic tool is the echocardiogram. It’s very simple and well tolerated. It places a probe on the chest wall, and it allows imaging of the heart to completely—It’s rather astounding. It’s like sonograms that you can really visualize all the chambers of the heart, the thickness of the walls, and most importantly how well it contracts and whether it effects both the left side of the heart and the right side of the heart. It is the national guideline first diagnostic test of someone that we think might have heart failure is to get an echocardiogram. Easy to obtain and it takes about 20 or 30 minutes and can be obtained in any hospital or large clinic treating patients with heart failure.
It gets more advanced. If we think that there’s a question that patients might have ischemic heart disease or coronary narrowing that has either been the cause of their heart failure or may be causing dysfunction at the time, they may require a cardiac catherization where we actually can inject dye into the coronary arteries and prove that that’s not there. They may have a measurement of the pressures in their heart and lungs. The number one diagnosis that really should suffice in most patients to unequivocally establish a diagnosis is the echocardiogram.
Host: Is this considered a chronic condition now? As you mentioned five years out depending on when it’s found or your age and other comorbidities. Do you look at this as something now, Dr. Miller, that is managed as opposed to cured or treated in some way?
Dr. Miller: It’s a really important question. Unfortunately, I’d have to say that’s it’s a management. I think with really more aggressive and attentive care, we can hopefully extend this. It is a progressive disease. Like many other chronic diseases, it has variable progression. So that not everyone, those are averages. So other people may well get under good medical management and survive for 10 years, and others may find progression, unfortunately, that becomes more symptomatic and limiting in a shorter period of time.
Host: What about diet? You mentioned that they could have swelling in their legs and feet. Tell us where diet and salt and the things that we eat can contribute to or help with heart failure.
Dr. Miller: That’s really the starting point, and we’ll talk in a minute about the advances in medical therapy and oral drugs that can help really improve the symptoms and the function of the heart. But we really start with salt and water ingestion. Salt has the pension for causing a retention of fluid in the body. We see people who may be salt advocates and enjoy eating salt with many of their meals, but when we find patients with any form of heart failure, we try to reduce that. I don’t think it needs to be draconian, but in general we ask that they not cook with salt or add salt at the table and use salt substitutes.
We address that very much in the first several office visits when we initially begin helping to manage a patient with heart failure, but we also talk about fluid ingestion. Many of these people need a so called diuretic or a pill that will help clear salt and water and fluid in the body. We find that patients get thirsty and so they go back and they're drinking a substantial amount of fluid. So salt sets you up to hold onto fluid, but if you take an excessive amount of fluid, that will always lead to an increase in edema and swelling. So we absolutely start with trying to manage salt and water intake.
Then we progress to what are national American Heart Association guidelines of medications. We try not to get into polypharmacy or using multiple medications, but we do find that heart failure is a symptom of a broad compensatory response of the body to reduce function or impaired function. All of those are different mechanisms. Therefore, we end up quite often using two or three different types of drugs, but it is an algorithm or a progression of adding medicines based on response or lack of response in patients. As I mentioned before, the diuretics are the first line of therapy in most patients, but we try to never use a diuretic as monotherapy, as just that. Because it causes electrolyte depletion and it really doesn’t change the heart’s pumping function. It simply manages symptoms.
The current guidelines now include, as the first line drug, is a relatively new drug that you’ll see in television commercials called Entresto. It’s because this has been tested in an 8,000 patient international trial and found to be the most effective at improving heart function, reducing hospitalizations, and improving survival over what we had before. So that is, in those patients with reduce systolic function type of heart failure, about half the population. The second line, or would be used in patients with preserved function, may be a so called ACE inhibitor, like lisinopril. Or it could be other drugs because the most common coexisting problem, if not cause of the patients who are typically older and have preserve pumping function, but impaired relaxation is that they have high blood pressure. The patients with reduced heart function more typically have low blood pressure. So it’s somewhat easier to treat patients with the higher blood pressure type of impaired heart function because it opens up a number of options.
But a second drug that is very commonly used and prescribed is the class of drugs called beta blockers. That may be agents, specifically metoprolol or carvedilol or sotalol. They all end in an ‘ol’. These are drugs that really block the body’s sympathetic response, which means it increase their resistance, it increases their heart rate. Again, just a wealth of data in international trials proving that these drugs have a very important benefit in improving heart function, but also reducing mortality. So we really see--One of the things that I spent a lot of time with is that physicians have understood the need for these drugs, but they, unfortunately, don’t get to guideline dosing. So it’s really important if a patient is diagnosed with heart failure that one, they're on the right drugs. But secondly, that they're on the right doses. We work with patients to try and titrate them to get to what the studies have shown is the best dose. So it’s an important part of their management is good medical therapy and try to make it as simple as we can depending on the severity of their symptoms.
Host: Dr. Miller, looking forward to the next 10 years in the field, where do you see heart failure research going? What’s exciting that we might want to know about on the horizon? Please wrap it up for us. Give us your best advice about preventing heart failure, recognizing those symptoms, and getting in for our well visits and to see our doctors when we think there’s something going on.
Dr. Miller: Sure. There’s a lot of new things coming, but I think that we’re really aware of how rapidly this condition is progressing. And that it’s really going to become even more focused on patients with advanced stage and preserved heart function. So I think in patients who developed increasing shortness of breath when they exercise or find themselves with puffiness in their feet or ankles or difficulty breathing that they should see someone, a physician, ideally a cardiologist to help make this diagnosis and get on the right medicines. There are just a host of new medications coming. We have clinical trials now with a couple of new investigative drugs. But we’re also working with new advances including stem cells and genes as we understand more about the mechanisms of heart dysfunction and we’re able to alter it with these new research trials. So encourage people to keep that as a potential part of their future.
I want to finish with perhaps the most important part, and that is prevention. That is weight control, blood pressure control, and exercise. All of these factors can limit this. Diabetes is one of the fastest growing causes of heart failure. High blood pressure is an important cause of that. Atherosclerosis and ischemic heart disease. So pay attention to diet, exercise, smoking cessation are all the most important preventions to prevent the development of heart failure.
Host: Thank you so much, Dr. Miller, for coming on with such great information about the prevalence and the things that people can do to hopefully prevent it in the first place. Thank you, again, for joining us. You're listening to BayCare Health chat. For more information, please visit baycare.org. That’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.