Heart Failure: There is Excitement in the Air

Clyde W. Yancy MD, MSc discusses high-level treatment options for heart failure based on the ACC/AHA heart failure guidelines. He shares that heart failure is not inevitable but can be indeed prevented. He examines why the SGLT2-inhibitor story is exciting, how it came about and what the practitioner should do today with this new information.
Heart Failure: There is Excitement in the Air
Featured Speaker:
Clyde W. Yancy, MD, MSc
Clyde W. Yancy, MD, MSc is a cardiologist and chief of the division of cardiology at Northwestern Memorial Hospital, and a past president of the American Heart Association.

Dr. Yancy has received recognition for clinical and research expertise in the field of heart failure and has additional interests in cardiomyopathy, heart valve diseases, hypertension and prevention. He is also associate director of Northwestern Medicine Bluhm Cardiovascular Institute, and is the Magerstadt Professor of Medicine, professor of medical social sciences, and vice-dean of diversity and inclusion at Northwestern University Feinberg School of Medicine.

Learn more about Clyde W. Yancy, MD, MSc
Heart Failure: There is Excitement in the Air

Melanie Cole (Host):  We’re talking about heart failure. There is excitement in the air. My guest is Dr. Clyde Yancy. He’s the Chief of Cardiology in the Department of Medicine at Northwestern Medicine. Dr. Yancy, it’s a pleasure to have you with us again. Before we get into our topic, please give us a brief explanation of how the kidney and heart are inextricably linked with acute or chronic disorder of one organ system capable of damaging the other.

Clyde Yancy, MD (Guest):  It’s really important that we begin to understand that we can no longer take disease entities and put them in buckets that everything is interconnected because it’s not just the heart and the kidneys but it’s the heart and the bone marrow for example was some of the most recent work or it’s the cardiovascular system and the environment. Something that we haven’t considered before. We have to recognize that this phenomenon that we call systems biology is not only beginning to dictate a better way for us to understand health and disease, but also exposing new directions, new interventions, new targets for therapy and that’s uniquely the case when we think about this heart kidney interface because there’s a brand new class of drugs that seems to have a beneficial effect on both that was never intended to be at the outset.

Host:  Then how do you qualify that heart failure is not necessarily inevitable but can indeed be prevented and why is that so exciting?

Dr. Yancy:  So, we really are beginning to articulate why many of us who have been in the field for some time and particularly why patients and their families who are dealing with this condition can at least think about things in a more optimistic way and for those of us that are more deeply involved, there is reason for excitement. So, let’s take the first reason.

We have traditionally made everyone aware that as a function of getting older, we have between a one in five or one in three chance of developing heart failure. That’s almost stating it as an inevitability and that it’s just randomness whether you get it or not. But that is not correct. We now have very clear evidence that if we target the appropriate treatment of high blood pressure in the right patients in the right way; we can prevent heart failure. We now have clear evidence that if we treat diabetic patients with new drugs that have demonstrated remarkably the ability to forestall or in fact prevent the onset of heart failure, we can prevent this condition and we can have a major impact and we’ve learned that if we really are strident in our efficacy for heart healthy lifestyles, that that in and of itself helps us prevent the disease.

So, think about these very strong levers. Three levers in particular. Treating hypertension, treating diabetes and applying lifestyle change we can fundamentally drop the likelihood of developing this condition. A conservative estimate let’s say that over 50% of heart failure is in fact preventable. When you think of the consequences of this disease and realize that it’s no longer an inevitability that it can be prevented; that’s reason for hope, that’s reason for optimism, that’s even reason to be excited.

Host:  Well, it certainly is. Please for us, if you would, speak about current unmet needs in the management of heart failure and how those needs may be addresses by focusing on the potential role of sodium-glucose cotransporter 2 inhibitors, the SGLT2.

Dr. Yancy:  So, there’s a lot in that question for us to consider and it’s a well-positioned question because it is exactly what patients who might have this condition want to know and practitioners that are treating this condition need to know.

We understand that heart failure for a long time has been associated with important comorbidities. We’ve never been able to manage the disease in the context of the comorbidity as well as we can now. Whether it’s heart failure and hypertension or in this case heart failure and diabetes; we can actually attenuate the risk of developing the disease, but also if the disease is already established and the patient has diabetes and even when the patient doesn’t have diabetes; these new compounds known as sodium-glucose cotransporter 2 inhibitors are able to change that natural history.

This really is a pause moment because for those of us that have been in this business for a while; once diabetes is established, we have always equated that to at least subclinical cardiovascular disease whether or not there was an overt cardiovascular disease process. Now we’re talking about treating the diabetes with a drug that dramatically reduces the cardiovascular complications in this case specifically heart failure. And then, in addition, for the patient with heart failure, we’ve now added another therapy in the treatment of symptomatic heart failure whether or not you have diabetes. That means then that we have added a pillar, think about this, a foundational element has been added to the treatment of heart failure. That’s pretty remarkable.

The last time we had a foundational element added was over five years ago with the neprilysin inhibitor angiotensin converting enzyme system blocker that is the ARB angiotensin receptor blocker and the last time before that takes us back to the introduction of beta blockers. It’s been years separate when we’ve been able to identify therapies that can change the history. We have a new one now.

Host:  Well as we have a new one now, the SGLT2 inhibitor story is indeed exciting. Tell us how it came about and what should the practitioner do today with this new information you are giving us?

Dr. Yancy:  So, let me be very clear. Today, the practitioner who is treating a patient with diabetes and in that treatment, algorithm sees potential to add this sodium-glucose cotransporter 2 inhibitor to the regimen realized that that step in and of itself will reduce the risk of eventually developing heart failure. That’s really, really good news and that reduction is about a 40% reduction based against the likelihood of developing heart failure. So, that’s something that the practitioner can do today.

Sometime in the next I think 12 to 18 months, the practitioner will also have an FDA indication that will say for the patient with heart failure add these drugs to the regimen as an additional way to improve outcomes. So you can exercise a prevention strategy today and within 12 to 18 months, you can exercise another treatment strategy that really can help your patients do well. Now what this means is that we’ve made life a little more challenging because as the primary care provider, even as a cardiologist we have to become facile with this brand new class of drugs in a way that previously only endocrinologists were able to use the drugs. Now we are talking about everyone considering the use of these drugs appropriately to reduce the burden of cardiovascular disease.

Host:  Is heart failure still a dismal diagnosis with limited treatment options? If you are talking about mortality, for patients with heart failure, with reduced ejection fraction; does this still remain high and why are we so excited now? How is this going to impact clinical practice?

Dr. Yancy:  So I am particularly pleased that you brought this question up. I’ve been in the business for 30 years and I recognize statements that are baked into our literature, that are baked into contemporary comments, things the patients can search online, that would argue that once you have the diagnosis of heart failure you have a greater than 30% chance of being dead within three to five years. Those are dismal numbers that rival most cancers.

But with very deliberate and steady work, over time, we’ve demonstrated that that natural history like we said before is not an inevitability. We understand now that when we do the right thing for the right patient with the best combination of medicines; we can substantially reduce that risk of death just something of the magnitude of maybe only 3 to 5% per year and really give patients who are struggling with this condition a much better prognosis than they ever had before.

Clearly, there is a science to treating patients with multiple drugs the requirements and the follow up scheme. There’s a situation that evolves where others in the healthcare environment like nurses, physician extenders have to be engaged but the theoretical benefit is real. If we take all of the known therapies for at least the most worrisome iteration of heart failure where the heart muscle is weak and not functioning properly; we can change that in a way, we never could before. So, clearly, it’s an important diagnosis still but it carries with it much less negative weight than it did in the past, so much so that many of us are trying to work to take failure out of the model. When you first get the disease, yes you heart failure, but we think we can treat you effectively so that failure is no longer the concept. We really do think we can talk about just treating the heart muscle disorder and getting to where patients can thrive, can have a better quality of life and can live longer and better. I think that’s the goal we should all have.

Host:  Well it certainly is. And thank you so much for that great information. What a fascinating topic Dr. Yancy. You are such a great guest as always. Thank you again. And that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at www.Heart.NM.Org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.