Transcription:
The Epidemic of Heart Failure

Melanie Cole (Host): Congestive heart failure affects more than five million Americans. Your cardiologist can help you manage the condition with lifestyle changes and medications leading to a longer, fuller life. My guest today is Dr. Samer Najjar. He’s the director of the Heart Failure program at MedStar Washington Hospital Center. Welcome to the show, Dr. Najjar. What is congestive heart failure?

Dr. Samer Najjar (Guest): Well, thanks for having me and thanks for taking the time to discuss heart failure which is a very important disease. It’s probably not talked about as much in public as we talk about some of the other cardiovascular diseases. The American Heart Association has done a really excellent job of educating the public about things like heart attacks and strokes because for those diseases, when you have symptoms, you have to go to the hospital very early because there are things that can be done and the longer you wait, the more injury can happen. Heart failure tends to be a little bit different in that it is also very common. In fact, as you mentioned in the beginning, there’s more than seven million people in the country, or about two and a half percent of the population that has heart failure. And, in fact, when you go to people over the age of 65, the numbers get even higher. So, approximately five percent of people over the age of 65 and ten percent of people over the age of 75 have heart failure. So, it’s a very prevalent disease. I call it now an epidemic of heart failure. It’s all around us. A lot of people have it. Some people know about it but others don’t. So, this is a very important epidemiologic project that we need to educate the public and let people start to know what heart failure is and what can be done about it. Heart failure, the difficult thing about it is that it doesn’t have one way that it presents itself. People have different feelings or symptoms that can tell them or that can tell their doctors, their healthcare providers that they have heart failure. Usually, people think about it when they see swelling of the legs. So, if your legs get swollen everybody thinks, “Aha! My body is retaining fluid, therefore I’m congested, therefore I have congestive heart failure.” But not everybody presents themselves based on swelling of the legs. Some people will pick it up because they’re getting more and more short of breath. For many people, they realize that they can do less and less. So, the amount of walking they can do before they have to stop just gradually and progressively, it gets worse and worse. Some people lose their appetite. Some people will get abdominal pain. So, there’s multiple or a myriad of different types of symptoms that people can have which makes it a little bit harder to distinguish who has heart failure and who does not. To make things even more complex, heart failure is not one disease. So, when people present with heart failure, often heart failure is the last manifestation of a whole different set of things that could have happened, all of which end up with heart failure. Just for the sake of simplicity, I’m going to break it down into two different types. There is one type which we call “heart failure with preserved ejection fraction” and then there’s another one which is “heart failure with reduced ejection fraction”. What that means is in the first type, when you do an ultrasound of the heart, when you look at the heart, the heart squeeze is normal. So, the heart is squeezing normally but in spite of the fact that it’s squeezing normally, it’s having difficulty getting blood to the rest of the body. That’s something that we in the medical field have struggled with for awhile because it’s not immediately obvious to us, why would you be in heart failure if your heart is pumping strongly? This is to be distinguished from the other type of heart failure where the heart muscle is weak. So, the heart is trying to pump but the muscle is weak and there it’s much more intuitive. “Well, if the muscle is weak, it’s having a hard time pumping the blood forward. Therefore, the blood will back up. It will back up into the lungs which is what makes us short of breath and then it backs up into the rest of the body and that’s how we start retaining fluid.”

Melanie: Dr. Najjar, who is at risk for heart failure? Are there certain risk factors that predispose somebody to this?

Dr. Najjar: Yes, there are definite well-known and well-described risk factors for heart failure. So, anything that can cause injury to the heart puts people at risk for having heart failure. So, people who have high blood pressure that is uncontrolled; people who have heart attacks; people who have blockages in vessels in the heart, and then the risk factors for that; people who are smokers; people who have high cholesterol. All of these people are predisposed to have a heart attack and when a heart attack happens, what happens with a heart attack is there’s a blockage in the vessels of the heart and, therefore, that part of the muscle of the heart doesn’t get blood flow and it dies and that leads to a weak heart. And so, this is a big risk factor, which all the risk factors that we think about classically and traditionally from a heart perspective, also high blood pressure alone is a risk factor. But, then, there are maybe thirty to forty percent of patients who develop heart failure who don’t have any of those risk factors and we don’t know why they develop heart failure. So, there are definite risk factors that can predispose people to having heart failure but, then again, some people don’t have any risk factors and it just happens. And, in minorities, it’s actually genetic. So, in some families, heart failure runs in the family that then have a genetic predisposition and they are set up for having it. But, it’s important to emphasize that there are known risk factors which is why these risk factors have to be addressed during the lifetime of a person. So, high blood pressure should be treated. High cholesterol should be addressed. Anybody who has diabetes or high blood sugar that also should be addressed. Smoking, people should be advised against smoking. There are also lifestyle things that are very important. Exercise is a huge risk factor modifier and our population needs to do much more physical activity and exercise than what is common—than what is being done now as well as obesity. So, all of these sort of go together, they go hand in hand in terms of creating risk factors for heart attacks and, as a result, they might lead to heart failure. Now, in the one case that I mentioned about the people that have the heart failure where the heart squeezes normal, there the risk factor tends to be older age, particularly older women who have high blood pressure and African American older women are at a particularly high risk for having that type of heart failure. The difference between these two types of heart failure is the following: in the heart failure where we have a weak heart, we actually have developed quite a bit of therapies for that. So, the first thing to be done when somebody develops this and when we identify it is we have to put the patient or the person on medication. There are a lot of medications that have been studied and there are several medications that have been shown without any doubt that they actually improve survival so people live longer and it makes people feel better. So, it is very important with anybody with heart failure that they are seen by their doctors and followed by their healthcare providers because they have to be put on these medications and the doses of these medications have to be adjusted until we hit the right dose. So, there’s a medication component to it. There’s also, for some people, devices such as pacemakers and defibrillators. Some people would need these devices because these devices can also help save their life and, for some people, it will also make them feel better. That’s what the healthcare team brings to the patient but also there are things that they themselves will need to do. For example, once somebody has heart failure and we call it “congestive heart failure” because the person is retaining fluids, they have to counteract that. So, salt is the big culprit. Salt in the body helps the body retain fluids so people who have heart failure, they need to avoid salt because that will help their body prevent the accumulation of fluid. The other thing is since they’re at risk for retaining this fluid, they have to monitor how much fluid they take in. So, oftentimes, we talk with patients about limiting how much water they drink or how much fluid they drink so as not to have it be retained in the body. So, salt is an important part of it, how much fluid is taken is an important part of it, exercise is absolutely critical, as you mentioned before, and in some people we even tell them that they have to weigh themselves on a regular basis because once the body starts retaining fluid, the first thing they will see, even before they have symptoms, is oftentimes the weight starts going up and that’s the time when we can actually intervene and do something about the weight.

Melanie: Are the medications that you put them on, is this now a lifetime thing? Do they have to be on these for the rest of their lives?

Dr. Najjar: Pretty much so. Some people, a minority of people, sometimes the heart can improve and they can come out of the heart failure and in those people, after they’ve been on the medication for awhile, we may be able to get them off but for the majority of people, when they go on these medications, they will be on these medications for their lifetime, yes.

Melanie: So, do you consider, Dr. Najjar, congestive heart failure now to be a chronic disease as opposed to something that happens that’s acute like a myocardial infarction?

Dr. Najjar: Absolutely. The heart failure is sort of a prototypical disease ,along with diabetes and hypertension, as being chronic conditions. This is not just a condition of, well, something happened and you ended up in the hospital, we treat you and you go home and it’s over with. Not at all. A heart failure is something a person’s going to live with for the rest of their life and they may or may not end up in the hospital for a period of time but what is more important is during the days when they’re at home or the weeks or months or years when they’re at home living with this, what are the lifestyle changes that they have to do for this? Because this does not go away. This is a chronic condition that is staying with them and so the lifestyle changes we talked about, the medications are important, and then the check-ups and the follow-ups with their healthcare team are important. In fact, now when somebody gets hospitalized, when they leave the hospital, we now call it not a “discharge” from the hospital but a “transition of care” because the hospitalization is just one small episode where things get adjusted but then they have to be carried forward after the person leaves the hospital. So, heart failure definitely is the prototypical or the ambassador of what we call, now, “chronic diseases”.

Melanie: So, wrap it up for us, Dr. Najjar, and give us your best advice about people that may be at risk for congestive heart failure, the lifestyle modifications and what you would like them to know.

Dr. Najjar: So, what people have to know is that anybody who has any risk factor for heart diseases, in general, they can’t just ignore them. They have to act on them because even though these things, they don’t hurt, they don’t lend you in the hospital if your blood pressure’s a little high, if your cholesterol’s a little high, you don’t feel it. You don’t know that you’re having a problem. You don’t want to wait until you have a problem, either a heart attack or heart failure. You have to be able to modify those risk factors in middle age, in young age, as soon as you find out that they happen because when you’ve already developed the disease, you’ve already lost the opportunity to prevent them. Once you do have the disease, once you do have symptoms that are such, either your legs are swelling or you’re getting more short of breath or you feel more tired than you felt before, it is important to talk to your doctor or healthcare provider so they can look into it and find out whether or not you have heart failure. If you do have heart failure, there are things that they can treat you with which will number one, make you feel better and number two, get you living longer.

Melanie: Thank you so much for being with us today, Dr. Najjar. It’s such important and great information. You’re listening to Medical Intel with MedStar 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.