Heart failure, also known as congestive heart failure (CHF), is a condition in which the heart cannot pump enough blood to the rest of the body. Many lifestyle choices can help prevent the chances of you developing the condition.
Dr. Ryland Melford, III MD, explains the socioeconomic impact of CHF, plus the current and future treatment strategies designed to reduce morbidity and mortality.
Congestive Heart Failure: Community Impact and New Treatment Paradigms
Featured Speaker:
Organization: Saddleback Memorial Medical Center
Dr. Melford's bio
Dr. Ryland Melford, III MD
Dr. Ryland Melford III completed medical school at Washington University School of Medicine, his residency at Barnes-Jewish Hospital, and a fellowship program in Cardiovascular Disease at University of Washington School of Medicine. Following his fellowship, he came to Southern California and began practicing as an Invasive Cardiologist. Dr. Melford is certified in Cardiovascular Diseases by the American Board of Internal Medicine and has a special clinical interest in heart failure management and cardiac imaging modalities.Organization: Saddleback Memorial Medical Center
Dr. Melford's bio
Transcription:
Congestive Heart Failure: Community Impact and New Treatment Paradigms
Deborah Howell (Host): Hello. Welcome to the show. You are listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I am Deborah Howell. Today's guest is Dr. Ryland Melford III. Dr. Melford is currently with the South Orange County Cardiology Group. His special clinical interest is in heart failure management and cardiac imaging modalities. Dr. Melford practices at Saddleback Memorial Medical Center and is very passionate about his topic today. Welcome, Dr. Melford.
Dr. Ryland Melford (Guest): Thank you. I'm happy to be here this morning.
Deborah: Today let's talk about congestive heart failure and some of the new treatments for this condition. As always, we like to start with a definition of what we're talking about. If you could, please tell us in layman's terms just what congestive heart failure involves.
Dr. Melford: Congestive heart failure is a bit of a misnomer to some degree when we use the word "failure." It's actually not my favorite word to describe the syndrome. Really, what we're talking about is an inability of the heart to pump sufficient blood to meet the body's needs, so a reduction in what we call cardiac output. What goes along with that syndrome typically are congestive symptoms, which is where the "congestive" term comes into play. That is the process that is associated with increased or excess volume of fluid, if you will, that can accumulate in the lungs or in the extremities and cause swelling. That's the general definition. It comprises those two elements, the reduction in pump function or inadequate blood supply to the body, and congestive symptoms.
Deborah: What would cause the pump to not perform optimally?
Dr. Melford: That's an excellent question. Sixty to 75 percent of cases, Deborah, are associated with ischemic heart disease. As you know, coronary artery disease is very common in our population. When a person suffers a hear attack, the consequences of that are often some degree of pump failure because some of the heart muscles died. That would be the most common cause. Other causes that are relatively prevalent, especially in the United States and in developed countries, are hypertension, a valvular heart disease such as mitral regurgitation, or aortic stenosis. There are rare phenomena as well that can cause the diagnosis. Those are the primary elements that we see in this country.
Deborah: In 30 seconds, you just clarified for me. Both my mother and my sister were affected by this, and I never understood it. Thank you so much, because now I see the muscles weakening in the heart, and I can understand why that would affect the pumping. Thank you very much for your clear assessment of that. What are the current treatment strategies available to patients with CHF today at Saddleback Memorial?
Dr. Melford: At Saddleback Memorial, we exist in a unique circumstance. As you know, we're physically adjacent to Laguna Woods Village, which is a very large greater than 25,000-person elderly community. It's important to remember that this is a disease of the elderly. Ten percent of those over the age of 65 have heart failure. We have worked very hard for several years to develop an optimal strategy to take care of these patients. I think this can't be stressed enough. That begins with medication. Beginning in the '90s, there were several clinical trials that demonstrated that medications like ACE inhibitors, beta blockers, angiotensin receptor blockers, aldosterone antagonists, specific classes of medication could not only improve symptoms in patients with heart failure but also reduce mortality and make them live longer. This was unique. We certainly focused first on medication. We've been recognized by the American Heart Association with their gold classification for Get with the Guidelines, which basically identifies us as an institution that is in adherence with the national guidelines for medication utilization. We've had that certification since 2006. I would say though that more recently, there's been a transition in the paradigm of focus for heart failure management towards more device-based care. We have implemented those therapies in Saddleback as well. For instance, we have the capacity to implant cardioverter-defibrillators, which is a device that can pace or shock the heart if the patient develops a life-threatening rhythm disorder and can reduce a likelihood of death by up to 25 percent in the clinical trial. We have the capacity to place special pacemakers that more recently have been shown to improve symptoms and mortality, and we call those high-ventricular pacemakers, or high-ventricular defibrillators. So this is a relatively new strategy. Obviously, we have the capacity to revascularize those that have coronary artery disease—the most common cause of heart failure—with either percutaneous techniques through the skin, like angioplasty and stenting, or bypass surgery when that's indicated. At Saddleback, we actually have the capacity to perform off-pump bypass surgery, which is a little bit safer in some patient populations. Lastly, I would say we're looking to partner with some of the local tertiary care institutions so that we can be on the cutting edge. There are new therapies coming out—gene therapy, some stem cell-based therapies—that we're very excited about participating in the development of. That's a general overview of what we do. The one thing I would add, and I will quickly say this, is that we also have the setup to evaluate patients who have these therapies. We have a special pacemaker and arrhythmia clinic at Saddleback. That allows us to follow those who have these devices and optimize them. That's a general overview of what we have in terms of therapeutic possibilities for this population of patients.
Deborah: I would say that's more than a handful of wonderful options. It sounds like mostly with a small surgery, because I'm assuming the pacemaker surgery is getting ever more patient-friendly. Am I right?
Dr. Melford: Certainly. Absolutely. We consider it minimally invasive at the present. Typically, a pacemaker patient goes home the morning after their implant.
Deborah: Is it done robotically, or is it still done surgically by a surgeon's hands?
Dr. Melford: Now it's actually done for the most part by a cardiologist now in the catheterization lab. The pacemaker generally involves a quick anatomy lesson. Wires are placed through a person's veins after they've been anesthetized and made comfortable. Those wires, or what we call electrodes, are then placed in the heart to perform the pace-making or defibrillator function. There's just a very small battery or generator that's usually in the patient's upper chest. Most people—I'd say the great majority—tolerate these devices very well, because they don't make noise typically, et cetera, et cetera. It's not something that the patient notices other than the fact that they're able to go about their day with the reassurance that they have there, if you will, to keep an eye on things and make sure their heart works well.
Deborah: I'm so, so curious. It's such a wonderful thing that you're doing this already. But in the future, I would love for you to outline real quickly what some of the stem cell treatments might look like for a patient in the future.
Dr. Melford: That is a fantastic question. That is actually one of my specific clinical interests there from the time when I as a fellow. Really quickly, when a person has a heart attack and the heart muscle cells die, they do not have the capacity of some of the other cells in the body to regenerate. A scar is left. The goal with stem cell therapy and what we're hopeful for in the future is that we'll be able to find a mechanism to deliver patient premature cells, if you will—so a patient premature cells that haven't been differentiated into heart cells or nerve cells or skin cells yet—and stimulate those cells to develop into a functioning element of heart muscle, a functioning that would replace the scar left by the heart attack or whatever other process that compromised the person's functioning. We're not there yet. We're very early in the clinical trials and developmental trials, if you will, for this therapy. It's very exciting. I can't give you a timeframe, but I can tell you that all of us in heart failure are incredibly interested in the possibilities for this therapy as well as gene therapy.
Deborah: Maybe someday we won't have to call it failure. Maybe we can get that word out of there.
Dr. Melford: That's something that I'd like to pioneer if I could and be involved in. It's a challenging word for patients. When you hear failure, the connotation of that word I think is inappropriate. It scares people, for whatever reason.
Deborah: Replace it with challenge.
Dr. Melford: I like that.
Deborah: We have just a couple of minutes, but we could talk real briefly about gene therapy.
Dr. Melford: The evaluation for gene therapy is just beginning. The really quick example I can give you is with the gene called Circa 2. What we've identified is that patients who have heart failure have abnormal metabolism of calcium in their heart cells. Calcium is responsible for helping heart cells contract or function. The abnormal calcium regulation, if you will, within heart cells has been effectively modified in some mice models and some animal models using a specific gene that is involved in calcium metabolism. An injection of this gene has been shown to improve function in some population. Again, we're far away, but we're getting closer.
Deborah: Wonderful. Thank you so much, Dr. Melford. Let's do a whole other show together on stem cell. Thanks so much for your time and your expertise today. We really appreciate it.
Dr. Melford: Thank you very much, Deborah.
Deborah: I'm Deborah Howell. Join us again next time as we explore another weekly dose of wellness brought to you by MemorialCare Health System. Have a great day.
Congestive Heart Failure: Community Impact and New Treatment Paradigms
Deborah Howell (Host): Hello. Welcome to the show. You are listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I am Deborah Howell. Today's guest is Dr. Ryland Melford III. Dr. Melford is currently with the South Orange County Cardiology Group. His special clinical interest is in heart failure management and cardiac imaging modalities. Dr. Melford practices at Saddleback Memorial Medical Center and is very passionate about his topic today. Welcome, Dr. Melford.
Dr. Ryland Melford (Guest): Thank you. I'm happy to be here this morning.
Deborah: Today let's talk about congestive heart failure and some of the new treatments for this condition. As always, we like to start with a definition of what we're talking about. If you could, please tell us in layman's terms just what congestive heart failure involves.
Dr. Melford: Congestive heart failure is a bit of a misnomer to some degree when we use the word "failure." It's actually not my favorite word to describe the syndrome. Really, what we're talking about is an inability of the heart to pump sufficient blood to meet the body's needs, so a reduction in what we call cardiac output. What goes along with that syndrome typically are congestive symptoms, which is where the "congestive" term comes into play. That is the process that is associated with increased or excess volume of fluid, if you will, that can accumulate in the lungs or in the extremities and cause swelling. That's the general definition. It comprises those two elements, the reduction in pump function or inadequate blood supply to the body, and congestive symptoms.
Deborah: What would cause the pump to not perform optimally?
Dr. Melford: That's an excellent question. Sixty to 75 percent of cases, Deborah, are associated with ischemic heart disease. As you know, coronary artery disease is very common in our population. When a person suffers a hear attack, the consequences of that are often some degree of pump failure because some of the heart muscles died. That would be the most common cause. Other causes that are relatively prevalent, especially in the United States and in developed countries, are hypertension, a valvular heart disease such as mitral regurgitation, or aortic stenosis. There are rare phenomena as well that can cause the diagnosis. Those are the primary elements that we see in this country.
Deborah: In 30 seconds, you just clarified for me. Both my mother and my sister were affected by this, and I never understood it. Thank you so much, because now I see the muscles weakening in the heart, and I can understand why that would affect the pumping. Thank you very much for your clear assessment of that. What are the current treatment strategies available to patients with CHF today at Saddleback Memorial?
Dr. Melford: At Saddleback Memorial, we exist in a unique circumstance. As you know, we're physically adjacent to Laguna Woods Village, which is a very large greater than 25,000-person elderly community. It's important to remember that this is a disease of the elderly. Ten percent of those over the age of 65 have heart failure. We have worked very hard for several years to develop an optimal strategy to take care of these patients. I think this can't be stressed enough. That begins with medication. Beginning in the '90s, there were several clinical trials that demonstrated that medications like ACE inhibitors, beta blockers, angiotensin receptor blockers, aldosterone antagonists, specific classes of medication could not only improve symptoms in patients with heart failure but also reduce mortality and make them live longer. This was unique. We certainly focused first on medication. We've been recognized by the American Heart Association with their gold classification for Get with the Guidelines, which basically identifies us as an institution that is in adherence with the national guidelines for medication utilization. We've had that certification since 2006. I would say though that more recently, there's been a transition in the paradigm of focus for heart failure management towards more device-based care. We have implemented those therapies in Saddleback as well. For instance, we have the capacity to implant cardioverter-defibrillators, which is a device that can pace or shock the heart if the patient develops a life-threatening rhythm disorder and can reduce a likelihood of death by up to 25 percent in the clinical trial. We have the capacity to place special pacemakers that more recently have been shown to improve symptoms and mortality, and we call those high-ventricular pacemakers, or high-ventricular defibrillators. So this is a relatively new strategy. Obviously, we have the capacity to revascularize those that have coronary artery disease—the most common cause of heart failure—with either percutaneous techniques through the skin, like angioplasty and stenting, or bypass surgery when that's indicated. At Saddleback, we actually have the capacity to perform off-pump bypass surgery, which is a little bit safer in some patient populations. Lastly, I would say we're looking to partner with some of the local tertiary care institutions so that we can be on the cutting edge. There are new therapies coming out—gene therapy, some stem cell-based therapies—that we're very excited about participating in the development of. That's a general overview of what we do. The one thing I would add, and I will quickly say this, is that we also have the setup to evaluate patients who have these therapies. We have a special pacemaker and arrhythmia clinic at Saddleback. That allows us to follow those who have these devices and optimize them. That's a general overview of what we have in terms of therapeutic possibilities for this population of patients.
Deborah: I would say that's more than a handful of wonderful options. It sounds like mostly with a small surgery, because I'm assuming the pacemaker surgery is getting ever more patient-friendly. Am I right?
Dr. Melford: Certainly. Absolutely. We consider it minimally invasive at the present. Typically, a pacemaker patient goes home the morning after their implant.
Deborah: Is it done robotically, or is it still done surgically by a surgeon's hands?
Dr. Melford: Now it's actually done for the most part by a cardiologist now in the catheterization lab. The pacemaker generally involves a quick anatomy lesson. Wires are placed through a person's veins after they've been anesthetized and made comfortable. Those wires, or what we call electrodes, are then placed in the heart to perform the pace-making or defibrillator function. There's just a very small battery or generator that's usually in the patient's upper chest. Most people—I'd say the great majority—tolerate these devices very well, because they don't make noise typically, et cetera, et cetera. It's not something that the patient notices other than the fact that they're able to go about their day with the reassurance that they have there, if you will, to keep an eye on things and make sure their heart works well.
Deborah: I'm so, so curious. It's such a wonderful thing that you're doing this already. But in the future, I would love for you to outline real quickly what some of the stem cell treatments might look like for a patient in the future.
Dr. Melford: That is a fantastic question. That is actually one of my specific clinical interests there from the time when I as a fellow. Really quickly, when a person has a heart attack and the heart muscle cells die, they do not have the capacity of some of the other cells in the body to regenerate. A scar is left. The goal with stem cell therapy and what we're hopeful for in the future is that we'll be able to find a mechanism to deliver patient premature cells, if you will—so a patient premature cells that haven't been differentiated into heart cells or nerve cells or skin cells yet—and stimulate those cells to develop into a functioning element of heart muscle, a functioning that would replace the scar left by the heart attack or whatever other process that compromised the person's functioning. We're not there yet. We're very early in the clinical trials and developmental trials, if you will, for this therapy. It's very exciting. I can't give you a timeframe, but I can tell you that all of us in heart failure are incredibly interested in the possibilities for this therapy as well as gene therapy.
Deborah: Maybe someday we won't have to call it failure. Maybe we can get that word out of there.
Dr. Melford: That's something that I'd like to pioneer if I could and be involved in. It's a challenging word for patients. When you hear failure, the connotation of that word I think is inappropriate. It scares people, for whatever reason.
Deborah: Replace it with challenge.
Dr. Melford: I like that.
Deborah: We have just a couple of minutes, but we could talk real briefly about gene therapy.
Dr. Melford: The evaluation for gene therapy is just beginning. The really quick example I can give you is with the gene called Circa 2. What we've identified is that patients who have heart failure have abnormal metabolism of calcium in their heart cells. Calcium is responsible for helping heart cells contract or function. The abnormal calcium regulation, if you will, within heart cells has been effectively modified in some mice models and some animal models using a specific gene that is involved in calcium metabolism. An injection of this gene has been shown to improve function in some population. Again, we're far away, but we're getting closer.
Deborah: Wonderful. Thank you so much, Dr. Melford. Let's do a whole other show together on stem cell. Thanks so much for your time and your expertise today. We really appreciate it.
Dr. Melford: Thank you very much, Deborah.
Deborah: I'm Deborah Howell. Join us again next time as we explore another weekly dose of wellness brought to you by MemorialCare Health System. Have a great day.