Samer Najjar, MD, director of the Advanced Heart Failure Program at MedStar Heart & Vascular Institute at MedStar Washington Hospital Center, discusses the epidemic of heart failure in the United States.
He shares best practices for determining the classifications of heart failure, including how to assess patient history, and the threshold at which they cross over into advanced heart failure. He discusses a range of therapies including inotropes, implantable devices, transplant, and end-of-life care.
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Advanced Heart Failure
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Learn more about Samer S. Najjar, MD
Samer Najjar, MD
Samer S. Najjar, MD, is the Director of Heart Failure at the MedStar Washington Hospital Center. He specializes in advanced therapies for heart failure, including the medical management of heart transplantation and ventricular assist devices. Prior to these positions, Dr. Najjar was an Assistant Professor of Medicine at Johns Hopkins University, and he was the Director of the Heart Failure clinic at the Johns Hopkins Bayview Medical Center. He was also the Head of the Human Cardiovascular Studies Unit at the National Institute on Aging. Dr. Najjar has more than 60 publications in peer-reviewed journals. His research interests are arterial-ventricular coupling, cardiovascular aging, clinical heart failure.Learn more about Samer S. Najjar, MD
Transcription:
Advanced Heart Failure
Melanie Cole (Host): Heart failure is a very common condition affecting more than five million Americans. With more serious cases of heart failure, and when it progresses to an advanced stage, difficult decisions must be made between the doctor and their patient. My guest today is Sameer Najjar. He is the Director of the heart failure program at Med Star Washington Hospital Center. He specializes in advance therapies for heart failure, including the medical management of heart transplantation and ventricular assist devices. Welcome to the show, Dr. Najjar. Tell us a little bit about heart failure and the classification of it.
Dr. Sameer Najjar (Guest): Thank you very much for having me. As you mentioned heart failure is very prevalent. In fact, I now say we're having an epidemic of heart failure at the country because of the millions of people who have it. Not only is it very prevalent, it is also very expensive. It's one of the largest expenses for Medicare. It has a higher morbidity and a high mortality, a lot of hospitalizations, a lot of people who get readmitted or re-hospitalizations, and about 300,000 people die every year of heart failure. Now the classification of heart failure is based in large part on symptoms. We classify people as a Class 1, 2, 3 or 4. A Class 1 person is somebody who has absolutely no symptoms. So, they may have a weak heart but they could be up, outside running and doing all sorts of activities that they want. A Class 4 person, at the other extreme, is somebody who could barely do anything. They are having shortness of breath or fatigue, tiredness--just sitting down and not doing much. In between, the Class 2 and Class 3, the Class 2 people are those who can do activities but maybe not as much as somebody who is a Class 1. The Class 3 is somebody who's struggling, who can do stuff but they're struggling. For example, they can maybe not even walk two blocks. They can walk a block, so they're not housebound or bed bound, but they're certainly very symptomatic. For most patients with heart failure, the standard treatment involves medication. There's a whole set of medications that have been proven to help patients with heart failures and they're prescribed quite well for patients who have the heart failure condition and they're supplemented by devices, so things like defibrillators and pacemakers, which have also been shown to help patients with heart failure. Like I said, most patients with heart failure do well with these, but over time, the heart failure oftentimes progresses, it becomes more severe and these medications become less and less efficacious. The person who is initially Class 1, for example, may find themselves going on to Class 3 and get close to a Class 4. Now you have somebody who is really very limited, and by limited, I mean they're not able to do much. They're not able to live a good life, their quality of life is not good, they are not able to do activities that are meaningful to them or to their families and caregivers, and so things are looking pretty bleak. At that point, we do have additional things to offer them, and so these therapies are, what we call “advanced heart failure therapies”, meaning that they are geared towards patients who have the advance stages of heart failure. The key question is, when does somebody cross that threshold of going to say, “Well, I just have heart failure,” to somebody who says, “Well, I have an advanced heart failure”? Unfortunately, we do not have a single blood test that we can do that says, “Ah! I measured this level, and therefore, I'm going to call you this, that you now have advance heart failure” but there are many clinical signs that can sort of give it away. So, if you have somebody who's trying to do their best, they are taking all their medications. They're doing what they're supposed to do. They're limiting the amount of fluid that they're taking, but, in spite of that, they keep retaining fluid. They keep ending up back in the hospital. Something that tells us that there's something that's changed in this person, and now this person is maybe sicker than we thought what they were six months or a year ago, to the point that those medications are not holding them anymore. Also, in some people, you start seeing while the blood pressure is going down and down, and the medications that we give standardly for heart failure, now we have to back down on the doses of these medications. That is another trigger that tells us, “Well, something is progressing.” There are multiple different things that can happen. The third thing is, some people start developing kidney injury or liver injury. In other words, there's an organ damage and so these are all triggers or markers that a person is progressing towards advanced towards advance heart failure. In a given individual, they don't have one specific pattern of how things progress, it varies from person to person. Some people don't have to be hospitalized. They're able to stay at home, but they tell you that they can't get out of bed. Some people don't retain fluids, but their kidneys and their liver are showing evidence of damage. Other people just keep retaining fluid, but their kidneys and liver are working fine. And so, there's not one simple thing that gives it away but there's a multitude of things that could happen, and one has to stay vigilant and watch for these things and when they happen, be able to act on them. I want to emphasize on one really important thing and that is that the most important thing are symptoms. Oftentimes what patients with heart failure do is they adapt their lifestyle to what their body allows them to do. You ask somebody, "How are you doing now?" They'll say, "I'm doing fine." Then you ask them, "Well, what are you doing now?" And they say, "I don't do anything, I watch TV all day." You ask them, “What you were doing a year ago?" They say, "A year ago I could take the dog out, I'd walk them, take a stroll on the beach, and all that." You ask them, "Why aren't you doing that anymore?" They reply, "Oh! I think I must be older age, or the weather's not good." So, they find excuses why they're not doing them and the reality is they just sense internally that they're not able to do activities, and, therefore, they stop doing them or slowly ramp them down. I think being very careful about taking a very good history and asking people about, number one, what is their activity level, and perhaps, even more importantly, how is that activity level different than what it was before? That is often the first marker that the heart failure is progressing. There is one test I should mention called the “cardiopulmonary stress test” that measures something called “peak oxygen consumption”, which over, over and over again in clinical trials have shown that the peak oxygen consumption is the best prognostic marker in patients with heart failure. But, unfortunately I have to admit that test is not widely available and is not widely used, so we can't rely on it. I think the clinical markers, particularly the history, in terms of what are the exercise tolerance and performance of a person, as well as thing such as re-hospitalization, and organ damage are markers that clinicians need to be aware of to try and distinguish who's progressing towards the advance heart failure. Now, when somebody is progressing towards advanced heart failure, what are the therapies that are available? We have therapies across the spectrum. For some people, it's really the end of the road, and the right thing for them to do is to help them, and their caregivers, and their families, discuss end of life issues and palliation and, eventually, hospice. That is the right thing to do for them. For other people, we have things to help them and those things can include either specific medications called “inotropes” or surgical therapies which includes LVAD and transplant. The LVAD, or left ventricular assist devices, are a relatively new therapy and really just took off within the past five or six years. We've had these therapies for two decades but earlier the technology was not that good. So, back in the ‘90's and in the early 2000, we had these devices that worked well for only a few months up to a year, and then they would be degraded after that, and so they're not a good long-term option. But, nowadays we have the second, even the third generation of left ventricular assist devices which are smaller than the first generation, the surgeries are easier, and both the surgeon and the cardiologist are better at the management of both peri-operatively and post-operatively of patients with left ventricular assist devices. So, we're able to get much better outcomes in patients who have these LVADs. The LVAD can be implanted in one of three configurations, either as a bridge for transplant, meaning somebody is eligible for transplantation but we are not able to hold them with standard medical therapy to get to the transplant, therefore, we need to do something in between to keep them alive and give them a good quality of life until they got the transplant, so we put in an LVAD. Now, some people do not qualify for transplantation, and in those patients they can get an LVAD as destination therapy, meaning we put in the LVAD and they are going to go home and spend the rest of their life on the LVAD, with the understanding of the reason that to do the LVAD is to get them better quality of life as well as more longevity. In some people, we're not yet sure whether or not they're candidates for transplantation, and, therefore, the LVAD is implemented as a bridge to, what we call “decision”, meaning we'll put the LVAD in now and then, down the line, in weeks or month afterwards we will decide whether a person is a candidate for heart transplant patient or not. Heart transplant is a time honored therapy for people with end stage heart failure. Heart transplant is an excellent therapy, and the average survival, the medial survival, is approximately 13 years. The Achilles Heel of heart transplantation has been, and will be, at least for the foreseeable future, the availability of donor hearts. There are far more people who need heart transplantation than there are hearts available to donate. That's why the LVAD has come into play because not everybody can wait on medication until they get a heart transplant.
Melanie: Dr. Najjar, are you seeing compliance issues when they start advancing towards advance heart failure with medications? Is that one of the reasons?
Dr. Najjar: Compliance issues can be a problem in the community and it sort of varies depending on multiple different factors. The people who have compliance issues when somebody has regular heart failure are going to be the same compliance issues when they progress towards to advanced heart failure. In general, people who are compliant when they have regular heart failure are probably going to stay compliant with advance heart failure. So, I don't necessarily view that compliance is what triggers somebody to progress, per se, although it may be accelerated, meaning if somebody is not taking their medication, their heart is not able to benefit from those medications so they may progress at a faster rate. But, it's not the compliance, per se, that is going to trigger them or tip them over. But, compliance is an issue. One of the things we didn't talk about is when we're evaluating people for these LVAD transplant, we do a very comprehensive assessment, and that assessment includes both the medical side of things, we need to understand how each organ system is functioning, but there's also a very important psychosocial assessment that's a component, that's part of it. We need to understand is the person compliant, is the person caring about their health, are they trying to do the right thing to help themselves? All these things come into play, particularly when you talk about something like heart transplantation where the resources are very scarce. So, you really have to be very careful about allocating those resources because you don't want to give it to the wrong person.
Melanie: Wrap it up for us, please, Dr. Najjar. Tell physicians what you want them to know about advanced heart failure.
Dr. Najjar: I think the most important point is to recognize that heart failure, which all physicians are seeing quite frequently, can progress to advanced stages, and, if it's not caught early, if we let it go, then the person can get go to the point where we don't have anything to offer them. But, if it's caught early, in this day and time, we do have good therapies to offer patients and, therefore, the critical part is to recognize it before it’s too late, because we could do things to help these patients.
Melanie: Thank you so much for being with us today, Dr. Najjar. It's a very informative segment. You're listening to Medical Intel with Med Star Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks for listening.
Advanced Heart Failure
Melanie Cole (Host): Heart failure is a very common condition affecting more than five million Americans. With more serious cases of heart failure, and when it progresses to an advanced stage, difficult decisions must be made between the doctor and their patient. My guest today is Sameer Najjar. He is the Director of the heart failure program at Med Star Washington Hospital Center. He specializes in advance therapies for heart failure, including the medical management of heart transplantation and ventricular assist devices. Welcome to the show, Dr. Najjar. Tell us a little bit about heart failure and the classification of it.
Dr. Sameer Najjar (Guest): Thank you very much for having me. As you mentioned heart failure is very prevalent. In fact, I now say we're having an epidemic of heart failure at the country because of the millions of people who have it. Not only is it very prevalent, it is also very expensive. It's one of the largest expenses for Medicare. It has a higher morbidity and a high mortality, a lot of hospitalizations, a lot of people who get readmitted or re-hospitalizations, and about 300,000 people die every year of heart failure. Now the classification of heart failure is based in large part on symptoms. We classify people as a Class 1, 2, 3 or 4. A Class 1 person is somebody who has absolutely no symptoms. So, they may have a weak heart but they could be up, outside running and doing all sorts of activities that they want. A Class 4 person, at the other extreme, is somebody who could barely do anything. They are having shortness of breath or fatigue, tiredness--just sitting down and not doing much. In between, the Class 2 and Class 3, the Class 2 people are those who can do activities but maybe not as much as somebody who is a Class 1. The Class 3 is somebody who's struggling, who can do stuff but they're struggling. For example, they can maybe not even walk two blocks. They can walk a block, so they're not housebound or bed bound, but they're certainly very symptomatic. For most patients with heart failure, the standard treatment involves medication. There's a whole set of medications that have been proven to help patients with heart failures and they're prescribed quite well for patients who have the heart failure condition and they're supplemented by devices, so things like defibrillators and pacemakers, which have also been shown to help patients with heart failure. Like I said, most patients with heart failure do well with these, but over time, the heart failure oftentimes progresses, it becomes more severe and these medications become less and less efficacious. The person who is initially Class 1, for example, may find themselves going on to Class 3 and get close to a Class 4. Now you have somebody who is really very limited, and by limited, I mean they're not able to do much. They're not able to live a good life, their quality of life is not good, they are not able to do activities that are meaningful to them or to their families and caregivers, and so things are looking pretty bleak. At that point, we do have additional things to offer them, and so these therapies are, what we call “advanced heart failure therapies”, meaning that they are geared towards patients who have the advance stages of heart failure. The key question is, when does somebody cross that threshold of going to say, “Well, I just have heart failure,” to somebody who says, “Well, I have an advanced heart failure”? Unfortunately, we do not have a single blood test that we can do that says, “Ah! I measured this level, and therefore, I'm going to call you this, that you now have advance heart failure” but there are many clinical signs that can sort of give it away. So, if you have somebody who's trying to do their best, they are taking all their medications. They're doing what they're supposed to do. They're limiting the amount of fluid that they're taking, but, in spite of that, they keep retaining fluid. They keep ending up back in the hospital. Something that tells us that there's something that's changed in this person, and now this person is maybe sicker than we thought what they were six months or a year ago, to the point that those medications are not holding them anymore. Also, in some people, you start seeing while the blood pressure is going down and down, and the medications that we give standardly for heart failure, now we have to back down on the doses of these medications. That is another trigger that tells us, “Well, something is progressing.” There are multiple different things that can happen. The third thing is, some people start developing kidney injury or liver injury. In other words, there's an organ damage and so these are all triggers or markers that a person is progressing towards advanced towards advance heart failure. In a given individual, they don't have one specific pattern of how things progress, it varies from person to person. Some people don't have to be hospitalized. They're able to stay at home, but they tell you that they can't get out of bed. Some people don't retain fluids, but their kidneys and their liver are showing evidence of damage. Other people just keep retaining fluid, but their kidneys and liver are working fine. And so, there's not one simple thing that gives it away but there's a multitude of things that could happen, and one has to stay vigilant and watch for these things and when they happen, be able to act on them. I want to emphasize on one really important thing and that is that the most important thing are symptoms. Oftentimes what patients with heart failure do is they adapt their lifestyle to what their body allows them to do. You ask somebody, "How are you doing now?" They'll say, "I'm doing fine." Then you ask them, "Well, what are you doing now?" And they say, "I don't do anything, I watch TV all day." You ask them, “What you were doing a year ago?" They say, "A year ago I could take the dog out, I'd walk them, take a stroll on the beach, and all that." You ask them, "Why aren't you doing that anymore?" They reply, "Oh! I think I must be older age, or the weather's not good." So, they find excuses why they're not doing them and the reality is they just sense internally that they're not able to do activities, and, therefore, they stop doing them or slowly ramp them down. I think being very careful about taking a very good history and asking people about, number one, what is their activity level, and perhaps, even more importantly, how is that activity level different than what it was before? That is often the first marker that the heart failure is progressing. There is one test I should mention called the “cardiopulmonary stress test” that measures something called “peak oxygen consumption”, which over, over and over again in clinical trials have shown that the peak oxygen consumption is the best prognostic marker in patients with heart failure. But, unfortunately I have to admit that test is not widely available and is not widely used, so we can't rely on it. I think the clinical markers, particularly the history, in terms of what are the exercise tolerance and performance of a person, as well as thing such as re-hospitalization, and organ damage are markers that clinicians need to be aware of to try and distinguish who's progressing towards the advance heart failure. Now, when somebody is progressing towards advanced heart failure, what are the therapies that are available? We have therapies across the spectrum. For some people, it's really the end of the road, and the right thing for them to do is to help them, and their caregivers, and their families, discuss end of life issues and palliation and, eventually, hospice. That is the right thing to do for them. For other people, we have things to help them and those things can include either specific medications called “inotropes” or surgical therapies which includes LVAD and transplant. The LVAD, or left ventricular assist devices, are a relatively new therapy and really just took off within the past five or six years. We've had these therapies for two decades but earlier the technology was not that good. So, back in the ‘90's and in the early 2000, we had these devices that worked well for only a few months up to a year, and then they would be degraded after that, and so they're not a good long-term option. But, nowadays we have the second, even the third generation of left ventricular assist devices which are smaller than the first generation, the surgeries are easier, and both the surgeon and the cardiologist are better at the management of both peri-operatively and post-operatively of patients with left ventricular assist devices. So, we're able to get much better outcomes in patients who have these LVADs. The LVAD can be implanted in one of three configurations, either as a bridge for transplant, meaning somebody is eligible for transplantation but we are not able to hold them with standard medical therapy to get to the transplant, therefore, we need to do something in between to keep them alive and give them a good quality of life until they got the transplant, so we put in an LVAD. Now, some people do not qualify for transplantation, and in those patients they can get an LVAD as destination therapy, meaning we put in the LVAD and they are going to go home and spend the rest of their life on the LVAD, with the understanding of the reason that to do the LVAD is to get them better quality of life as well as more longevity. In some people, we're not yet sure whether or not they're candidates for transplantation, and, therefore, the LVAD is implemented as a bridge to, what we call “decision”, meaning we'll put the LVAD in now and then, down the line, in weeks or month afterwards we will decide whether a person is a candidate for heart transplant patient or not. Heart transplant is a time honored therapy for people with end stage heart failure. Heart transplant is an excellent therapy, and the average survival, the medial survival, is approximately 13 years. The Achilles Heel of heart transplantation has been, and will be, at least for the foreseeable future, the availability of donor hearts. There are far more people who need heart transplantation than there are hearts available to donate. That's why the LVAD has come into play because not everybody can wait on medication until they get a heart transplant.
Melanie: Dr. Najjar, are you seeing compliance issues when they start advancing towards advance heart failure with medications? Is that one of the reasons?
Dr. Najjar: Compliance issues can be a problem in the community and it sort of varies depending on multiple different factors. The people who have compliance issues when somebody has regular heart failure are going to be the same compliance issues when they progress towards to advanced heart failure. In general, people who are compliant when they have regular heart failure are probably going to stay compliant with advance heart failure. So, I don't necessarily view that compliance is what triggers somebody to progress, per se, although it may be accelerated, meaning if somebody is not taking their medication, their heart is not able to benefit from those medications so they may progress at a faster rate. But, it's not the compliance, per se, that is going to trigger them or tip them over. But, compliance is an issue. One of the things we didn't talk about is when we're evaluating people for these LVAD transplant, we do a very comprehensive assessment, and that assessment includes both the medical side of things, we need to understand how each organ system is functioning, but there's also a very important psychosocial assessment that's a component, that's part of it. We need to understand is the person compliant, is the person caring about their health, are they trying to do the right thing to help themselves? All these things come into play, particularly when you talk about something like heart transplantation where the resources are very scarce. So, you really have to be very careful about allocating those resources because you don't want to give it to the wrong person.
Melanie: Wrap it up for us, please, Dr. Najjar. Tell physicians what you want them to know about advanced heart failure.
Dr. Najjar: I think the most important point is to recognize that heart failure, which all physicians are seeing quite frequently, can progress to advanced stages, and, if it's not caught early, if we let it go, then the person can get go to the point where we don't have anything to offer them. But, if it's caught early, in this day and time, we do have good therapies to offer patients and, therefore, the critical part is to recognize it before it’s too late, because we could do things to help these patients.
Melanie: Thank you so much for being with us today, Dr. Najjar. It's a very informative segment. You're listening to Medical Intel with Med Star Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks for listening.