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Scott Webb: Heart failure also known as congestive heart failure affects more than 6 million Americans. Heart failure happens when the heart muscle can no longer efficiently pump blood, which can lead to fluid build up in the lungs and limbs and cause shortness of breath. It is considered a life-threatening condition, but it can be managed to a great extent and healthcare professionals work closely with patients to help them avoid having to be readmitted to the hospital.

Controlling your risk factors for heart disease in general can help you avoid heart failure, which usually presents in patients in their 70s. That means controlling your blood pressure, maintaining a healthy weight and, if you have diabetes, controlling your blood sugar. Some cancer patients, however, have been known to develop heart failure after receiving cancer treatments, due to the side effects of some medications, such as for breast and colon cancers. Monitoring these patients' heart function during their cancer treatments can help avoid long-term heart damage.

And joining me today to help us tackle all of this as Dr. Vijay Rao. He's a board-certified cardiologist with Indiana Heart Physicians in Indianapolis and the Medical Director of Cardio-Oncology and Heart Failure at Franciscan Health. This is the Franciscan Health Doc Pod. I'm Scott Webb.

So Dr. Rao, thanks so much for your time today. We're basically going to talk about heart health and some of the causes of heart failure and so on. So you're a great guest to have on, an expert in the field. As we get rolling here, what are the major causes of heart failure?

Dr. Vijay Rao: Yeah. So that's a great question. I think what I'd first like to start off by saying is, you know, in our field, we're really trying to get away from the term heart failure. What we're really trying to say is that there's something called congested heart. And what do I mean by that? Well, it means when the heart is not pumping properly, the heart is mainly a muscle that pumps blood to the organs of the body, including the brain and multiple other organs. And in certain circumstances, the heart pump starts to not work properly. And so that is one aspect of the congested heart and then fluid builds up. The whole term congested really comes from the idea that fluid can build up in the lungs. It can fill up in the legs and people can get short of breath. And those are really some of the signs and symptoms of a congested heart. So that's one aspect.

There's a second aspect of the congested heart, which I like to term the stiff heart syndrome, where the heart is actually pumping really well, but the problem is it gets very stiff. And I liken this to, for example, your bodybuilder, who is lifting weight, gets very, very strong. But unfortunately, if you ask them to touch their toes, they're really not able to do that, because they're stiff. And the heart can also have that same sort of process where it becomes very thick and strong, but unfortunately it becomes very stiff. And when that happens, the pressure inside the heart starts to build up and then people again can develop that congested heart syndrome, where they start to have fluid building up in the lungs and in their legs. So that's kind of the two different aspects of the congested heart. There's one that's a pump problem. The other one, that's more of a stiffening and filling problem.

So in terms of what could cause some of these things, they're actually very different entities. So when you think about the first scenario where a patient's heart is not pumping properly, typically we think of folks who have had a heart attack. So when there's a lack of blood flow to parts of the heart muscle, that heart muscle becomes damaged and the overall pump function of the heart goes down. And that's what we term ischemic cardiomyopathy. Ischemic, meaning blockage. Cardiomyopathy means sick heart. And that's still predominantly the number one cause of reduced heart function in patients.

There are other causes of reduced pump function. There are toxins. Things like methamphetamines, alcohol, cocaine. There are hereditary conditions, so people can inherit this from their parents or their grandparents, and there are multiple other causes. So we sort of divide them into those categories.

With respect to the stiff heart syndrome, typically, we see that in older folks. We tend to see it more in post-menopausal women and they're seen much more commonly in patients who have significant obesity. So it really drives home the fact that we really need to be focusing on weight loss in so many of our patients, because it's a large driver of that stiff heart syndrome.

Scott Webb: Yeah, I hear what you're saying. And I am glad to kind of get your perspective on this, that the heart failure is perhaps not the most accurate way or the most sort of targeted or specific way of referring to this. When we think about, you know, congested heart or stiff heart, and we think about who's at the greatest risk for developing those issues, congestion and stiffness and so on, is it only folks who've had heart attacks or stroke? Or maybe you can give us some focus here, who really is at the greatest risk?

Dr. Vijay Rao: Yeah. I mean, I think, again, it really depends on what type we're really talking about. I think in terms of the reduced pump function aspect. There's certainly the heart attack side of it, but we see some of these types of scenarios even in young people. So particularly, in the hereditary forms of the sick heart, we will see people in their 20s and 30s coming in shorter breath and swelling in their legs.

Also young males are often at risk for something called myocarditis, where they can get a viral infection that attacks the heart and sometimes their heart can get quite weak. So really it's not a disease that is specific to a particular age. Really, at any age, you can develop these signs or symptoms of shortness of breath and fluid buildup in the legs and lungs.

From the stiff heart perspective, that typically tends to occur in older individuals. So we tend to see that more in folks over the age of 60, particularly individuals who've had high blood pressure that may not have been treated with medications often for years. As you can imagine, the heart is lifting that blood pressure, so the muscle gets thicker, the higher your blood pressure is. And that tends to happen over a lot of times. So again, we tend to see that stiff heart syndrome typically in folks over the age of 60. And we do see it more in folks who have higher body mass index. Obesity, as I mentioned earlier, is a real driving force behind a lot of the high blood pressure that can lead to the stiff heart syndrome.

Scott Webb: Yeah, that's going to be one of my takeaways today. Because I think there's this sort of feeling, at least when I was younger, it felt like, "Well, you don't really have to worry about your heart until maybe you're in your 70s, maybe 75, something like that. But as you say, younger patients can have issues. Obesity is a driver of that, family history, genetics behavior, lifestyle, and so on. So I think the natural followup here is what are the common symptoms of heart-related issues? Be it congestion, stiffness, whatever it might be, how do we know doctor that we're having an issue?

Dr. Vijay Rao: Yeah, no, that's a great question. I think some of the key symptoms that people need to look out for are shortness of breath. Otherwise, in the medical term, we call it dyspnea. And typically, that's you know, if you were able to walk to the mailbox and back without really much of a problem. And now, all of a sudden you're having to stop halfway there. You have to catch your breath for about 30 seconds to a minute and then resume your walking, that's typically a signal that something could be going on. And typically, we'll have people sort of chalk that up to, "Well, I'm just getting older and I've been more sedentary and, you know, that's why I'm getting shorter breath."

But, if it's new for you, I would definitely recommend, you know, bringing that up with your primary care doctor, because there certainly could be, you know, an underlying heart condition that could be occurring. And some of the other things to look out for again are swelling. So if you start to notice that your legs, if you can push your finger in on your ankle or on your shin, and you notice that it's denting and not coming back out appropriately, that's a term we call edema. That can be a sign of the congested heart, as well as wheezing or coughing. And in particular, if you're having difficulty breathing, when you're laying down at night and you find yourself propping yourself up on multiple pillows, that's another concern that you might be developing congested heart with fluid in your lungs.

And then lastly, you know, fatigue is another term that we use. There's so many different causes of fatigue. Again, we say we're getting older, we're sedentary, could be medications that we're taking, et cetera, depression. But it also can be a sign that something could be going on with your heart. If you just notice you're running out of steam, you don't have the energy to do what you used to be able to do.

Scott Webb: Yeah. And that's a good list. And as you say, always best to obviously see your primary care physician, to speak with them, to get your yearly physicals. And you've given us a sense of some of the things that we can be on the lookout for, be it family history, genetics. And certainly we could all probably stand to lose some weight, but obesity is a disease, of course, one that really needs to be treated by a physician and have a real plan for folks.

And when we think about the treatment options, the various treatment options that are available to people, maybe you can go through that, you know. I knew there'd been a lot of advances, you know, and I've done podcasts on TAVR and all this amazing technology and all the changes over the years. But just generally speaking, doctor, what's the treatment options 101 for folks who may be experiencing some of the issues we've discussed today?

Dr. Vijay Rao: Yeah. I mean, I think the first step would be, you know, an ounce of prevention is worth a pound of cure. So I think some of the key aspects I would tell your audience is, first off, know your numbers. And what do I mean by that? Well, Think about your blood pressure, you know, it's what we often term the silent killer because people often don't have a whole lot of symptoms and yet they can be running extremely high blood pressures. We all have a lot of stress in our lives and, you know, alcohol is another one that can drive up blood pressures. So knowing your number upfront is really important and treating that. There's so many excellent blood pressure medications, which are well-tolerated and very inexpensive thankfully now. So being able to get on some of those medications upfront can prevent the future downstream to congested heart down the road. So I would say maybe start with that.

But in terms of, you know, what are things patients can do themselves, I think there's a lot they can do. I think really, you know, the American Heart Association and American College of Cardiology recommend daily physical activity or exercise. Thirty minutes, five days a week of aerobic activity has tremendous heart protective benefits in terms of again preventing those downstream events.

From a medical perspective, certainly working with your provider, it's an exciting time because there are a number of new medications that have come out that have really changed the landscape of congested heart. If you're in those patients with reduced pump function, we now understand the underpinnings or mechanisms for why that occurs. So besides opening up blocked arteries faster, so people don't get damaged heart muscle, we actually have medications that block a lot of the bad hormones that are produced by your body when the heart is not pumping properly. And we've been able to target those.

So there's a medicine called sacubitril/valsartan otherwise known as Entresto, which has really been a breakthrough therapy in the last four or five years for patients with reduced heart function. There's another new class of medications called SGLT2 inhibitors, which amazingly enough were originally started as diabetic medications because they lower sugar, but it turns out they actually have very powerful effects at preventing congested heart. And it turns out that the mechanisms are really quite fascinating. I know most of your audience are probably aware of patients who've lost weight with the keto diet, where they're cutting out carbs and they're kind of focusing more on a protein-based approach to their diet. And this is essentially a keto diet for your heart. So it turns out that instead of using sugar or glucose, the heart muscle starts to use something called free fatty acids. And by doing so, it's much more efficient in what it can do. And it's really been an amazing breakthrough for patients with congested heart, both with the stiff heart syndrome, but also the reduced heart function. So those are some of the really exciting medications that have come out recently.

And then lastly, there's certainly a lot of structural interventional things that cardiology has been able to do. It's one of the reasons I'm so amazed by this field, is that sometimes people can have severely leaking heart valves that can lead to congested heart. And we now have ways to do that without cracking someone's chest open. So, certainly in certain circumstances, cardiothoracic surgery is still indicated, but we are now starting to do more of those procedures through the groin. And in fact, many people are able to get discharged from the hospital within one day of having a new valve.

You mentioned earlier something called TAVR, which is being able to replace the aortic valve through the groin often, which is just incredible and the results are really tremendous. And so there are all sorts of technologic advances that can help these patients out.

Scott Webb: Absolutely. You know, drug therapies, technology, as you said, it's really an exciting time. And one of my favorite things about hosting these is getting doctors and experts like yourself on who are really excited to go to work, really excited for these advances and being able to share all of this with patients, you know. And you've given us a really good sense of what we can do, right? Knowing our numbers, that knowledge is power. Losing weight, you know, getting some exercise every day, quit smoking, slow down in the drinking, you know, all of these things, great information today. And I'm wondering how does a hospital system like Franciscan Health help patients manage heart disease?

Dr. Vijay Rao: As the director of our heart failure program, you know, I'll just tell you, it really takes a village to take care of this population and Franciscan has a really tremendous team from nurses to advanced practice providers to navigators. We have congested heart navigators that do a lot of the education about daily weights and low salt diets.

There's really a programmatic approach. We're using some of the technology to help some of these folks. For example, there's a lot of evidence and data coming out with wearable devices like the Apple Watch and something called KardiaMobile. And so we're trying to incorporate a lot of this information into our daily work practice, so that, you know, patients are able to have real time data to help them in their health.

What's really amazing is when a patient sees, you know, the particular food that they ate for dinner on that weekend, and then get instant feedback about how that's impacting, for example, the pressure in their hearts, it is incredible what sort of behavioral changes can occur. So I think that's a really exciting new area of this field and of healthcare in general. And Franciscan is definitely trying to be a pioneer in that care.

Ultimately, we want everybody to have long healthy lives and what I've really enjoyed about working here is that, you know, the health care system really focuses on the patient, where they're at, and try to do everything in our power to give them the resources to make the best health decisions.

Scott Webb: Yeah, definitely. And you mentioned, prevention and I know because of your dual director role of Franciscan Heart Failure and Cardio-Oncology. So you kind of tie these things together. And I do want to ask you if there's a direct link there between the two. But you mentioned prevention and it's just better for us, it's just cheaper for the medical system and patients, if we can prevent, you know, heart issues, congestion, stiffness. If we can prevent cancer, it's always going to be cheaper to prevent those things than to treat them after you've been diagnosed. So maybe you can address that. And also, is there a direct treatment link between these heart issues we've discussed and cardio-oncology?

Dr. Vijay Rao: Yeah. Let me tackle that second one first. The cardio-oncology is really a newer field where, you know, patients often will have cancer. And what's amazing is the treatments have allowed them to live so much longer than they ever did in the past. And what ends up happening is they often end up surviving their cancer, but ultimately end up with cardiovascular disease as the next major focus. And the same is true on the other end. Patients are now surviving their heart attacks and living much longer than they had in the past, and then subsequently develop cancer.

So what that really has shown us, is that the two different conditions often co-exist and the risk factors are very much the same. I mean, you mentioned earlier tobacco use or smoking is a major risk factor for both different entities. Obesity, as we've mentioned before, is a risk factor often for malignancy or cancer as well as heart disease. So there is a link there.

Now, what's also really been interesting as we've learned is that many of these new treatments that are really improving cancer outcomes, the so-called precision medicine, with the ability to be able to biopsy a cancer and be able to figure out what exactly is going on with that cancer cell that makes it a cancer cell. We can subsequently target it and that's called molecular medicine or precision medicine. And that's really what's led to a huge breakthrough in cancer care.

But, unfortunately what's also happening is that those same specific pathways that the cancer is using to multiply are also used by normal physiologic tissue and in particular the cardiovascular system. So what we're seeing is while patients are having outstanding responses to their cancer chemotherapy, They're subsequently developing marked hypertension or high blood pressure. They're developing drops in heart function that can lead to the congested heart that we've been talking about today.

So it's this new realization that there are off treatment side effects that can occur from some of these therapies and what we're trying to do, as you mentioned, the word prevention, we're trying to prevent those events from happening. We want patients with cancer to have good cancer outcomes, but we also want them to have good overall outcomes and good cardiovascular outcomes. So what our field has really done is to try to, you know, engage with the oncologist early as these chemotherapy regimens are being set up, mitigate risk factors, you know, if the patient is smoking or has high blood pressure or has high cholesterol, for example, trying to get them on evidence-based therapies early, so that we can prevent some of those downstream effects. So that's really what that field is about. And I think, for me, it's been a wonderful way to kind of combine my healthcare interests with, you know, populations that really need a lot of resources and help because these are pretty severe diseases.

Scott Webb: For sure. Yeah. And as you've indicated today and no surprise to hear this great team approach at Franciscan, it really does take a village, right? But it also takes all of us doing our part. And you've given us a pretty clear path today about, you know, eating better, exercising, quit smoking, see our doctors, know our numbers and so on. So I think there's a lot of reason for optimism.

And as we wrap up here, doctor, and this has been really educational for me as I'm sure it has been for listeners as well, if you could just have like two takeaways for all of us, like, "Here's what you need to do today to reduce your risk of the congested heart or the stiff heart. Here's what you should do, listener." What would those be, doctor?

Dr. Vijay Rao: Yeah, I think, the two take home messages, I think we did talk about a lot of different things today, and it's been a pleasure being here and thank you for the invitation. I would say to your audience, number one is get routine health care. I think, you know, showing up and spending time in your primary care doctor's annual visits, I can't stress how important that is. I think we all get sort of in that mindset that we're busy with life and taking care of kids and having a stressful job. And the first thing that often goes is we say, "Look, I feel fine. There's no reason to go see the primary care doctor unless I have a problem." And I would argue that is the logic that we need to get over. We need to understand that prevention means this is the reason why we go for colonoscopies, even though you're not having symptoms to pick up a colon cancer. This is why showing up in your doctor's office for their annual visits to check on your blood pressure, to do a physical exam, to pick up things that you may not notice are going on would really be important. So I'd stress that to just really do your best to make a priority to go to your annual visits with your primary care doctor, and be able to do a lot of these preventative therapies.

The second thing I would take home, since we really did focus a lot here today on the congested heart, is if you're having signs or symptoms of worsening, shortness of breath, chest discomfort, difficulty breathing when you're laying down and particularly if you start noticing swelling that is new for you, these are reasons for you to absolutely bring this up with your primary care doc to start the workup, because you don't want that to progress. I've certainly seen patients who have noticed some swelling and then ultimately show up to the primary care doctor's office after about 30 to 40 pounds of fluid overload and then the patient ended up getting hospitalized, when literally if they had just called earlier with a concern, a lot of that could have been staved off. So I think those would be some of the two take homes that I would give to your audience.

Scott Webb: Well, a great education today, a great advice from an expert today. And I think it comes down to, you know, we all just have to listen to our bodies. We have to be proactive. We have to listen to experts like yourself, that prevention is key for all of us. So doctor, thanks so much for your time today, and you stay well.

Dr. Vijay Rao: Thank you so much for the opportunity.

Scott Webb: A great first step in learning more about your personal heart health is to make an appointment for a heart scan at Franciscan Health. This $49 task can get you on track for the best heart health by assessing your risk of a future heart attack. The heart scan also includes a personal consultation with a fitness coach. And to see if you qualify or to make an appointment, call (833) 238-0688 or go to franciscanhealth.org/screeningbundles.

And if you found this podcast to be helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.