Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And today, we're highlighting the joint scientific statement between the Heart Failure Society of America and the American Society of Preventive Cardiology on the prevention of heart failure. Joining me is Dr. Quentin Youmans. He's an Assistant Professor of Medicine in Cardiology at Northwestern Medicine.

Dr. Youmans, it's a pleasure to have you join us today. As we think of the integration of care models, the statement emphasizes that need for a paradigm shift in heart failure prevention and a proactive approach to early detection, can you discuss the importance? And I think this is just so important to highlight the multidisciplinary collaboration between heart failure specialists, preventive cardiologists, and primary care clinicians. How can establishing that specialized heart failure prevention clinic aid in fostering this collaboration?

Dr. Quentin R. Youmans: Thanks so much, Melanie. It really is a pleasure to be here and talk about something that is really near and dear to my heart. You know, I think an ounce of prevention is worth a pound of cure, really. And when we think about something as complex as heart failure and all of the needs and all of the things that contribute to heart failure, it's really important to start at the beginning.

So, what are the lifestyle things that patients should do in order to prevent heart failure? That's first. And I think that's very broad. That can include exercise, that can include nutrition. There are so many different aspects of the lifestyle that can contribute. But then, when we think about the risk of heart failure, specifically with stage A heart failure, we know that there are a number of comorbidities that often go together that can contribute. So, things like high blood pressure, diabetes, high cholesterol, obesity, things that are really rampant in our society today that really start from the initial care encounter that might be the primary care physician, that might be the nephrologist, that might be the endocrinologist. We all have a role to play to prevent heart failure. We need to be ag as aggressive as we can with the risk factors that we know contribute so that we can prevent it down the line.

Melanie Cole, MS: I certainly agree with you and the statement advocates for a risk stratified approach to help patients with this heart failure journey in every stage of their heart care. How do biomarkers-- we're learning so much more about this, Dr. Youmans, how does biomarkers and risk scores help to inform this assessment? And what role do non-traditional risk factors play in that overall risk stratification as we think about the risk factors that we always talk about, but there are some non-traditional ones that are involved here too.

Dr. Quentin R. Youmans: Absolutely. You know, I think biomarkers are going to play an increasingly important role because the most important aspect is that we want to catch heart failure early if it exists. And so, we can often use biomarkers like the BNP or the NT-proBNP. And if there's some elevation in those and patients have the appropriate milieu in terms of their diagnoses, we need to have a high index of suspicion and recognize that that's a person that we may need to intervene on more quickly.

The other aspects that you mentioned that's really important are the risk scores. And so more recently, one of my colleagues, Dr. Sadiya Khan, and her colleagues came out with a really wonderful PREVENT risk calculator. And that calculator is amazing because, yes, it takes into account that traditional risk factors, but it also adds in a component looking at chronic kidney disease because as we're recognizing now, cardiovascular, kidney, metabolic disease all go together. And they all help to inform risk. So, recognizing that CKD is an important component of the risk for heart failure. PREVENT really adds that in there.

And then, I think the really other exciting thing about PREVENT is that it adds in an element of the social determinants of health, specifically the ZIP code. And you talked a little bit about non-traditional risk factors. You know, we all know diabetes and high blood pressure and obesity, these are things that we've been talking about and discussing for many years.

A lot of the non-traditional risk factors are becoming increasingly important as well. I have a personal passion for the social determinants of health. We need to understand what those social determinants of health might be that any given patient might have in terms of detrimental social determinants, and do what we can as a medical establishment to try to address them, recognizing that food insecurity, access to healthy green spaces, the ability to exercise, right? We always recommend please get 30 minutes a day of exercise. But if patients can't afford, for example, to have a gym membership and their neighborhood isn't safe enough to go for a walk, how might they access that? And so, we need to think about all of these things when it comes to preventing heart failure and even treating heart failure if it does exist.

Melanie Cole, MS: Well, that is just a huge area that you opened up, which we don't have time for today. But those social determinants of health, and I know the American College of Sports Medicine does an American fitness index where they talk about all of that and the built environment, and that is more complex than you or I could learn about right now. But you're right, it is an amazing thing to notice all of those things that have an effect on heart disease and, as you say, prevention. So, that's such an important point that you bring up. Can you break down for us, Dr. Youmans, the statements proposed framework for primary, secondary, and tertiary prevention? Because I think all of that ties in together.

Dr. Quentin R. Youmans: Absolutely. You know, I think it was a really wonderful statement to work on with my colleagues and out in Journal of Cardiac Failure. So, you know, when we think about primary prevention, it really is being aggressive at addressing those risk factors, those traditional risk factors that we know exist. So if a patient has high blood pressure, being as aggressive as we can, getting them to the target blood pressure; if a patient has elevated cholesterol, the same thing, understanding why that might exist and doing as much as we can in terms of lifestyle and other medications, et cetera, to help to bring that cholesterol down. So, that's the kind of primary prevention aspect, aggressive in those patients who are stage A or stage B and have not actually developed heart failure.

In terms of secondary, we consider patients who actually have heart failure. So, those people who are stage C, they have the classic symptoms. We've diagnosed them with heart failure. One of the most important things when it comes to secondary prevention is guideline-directed medical therapy. Thankfully, especially for patients who have heart failure with reduced ejection fraction, we have a number of medications that we know are effective at keeping patients out of the hospital, helping them live longer, helping them feel better. And so, optimizing those GDMT, that guideline-directed medical therapy is hugely important.

The really exciting piece is that in heart failure with preserved ejection fraction, HFpEF, an area that we've kind of lacked understanding for a number of years and we've gained a lot of understanding in the last decade, plus we are now coming out with a lot of really exciting medications that not only can help treat the HFpEF itself, but also the underlying conditions that contribute to HFpEF; recognizing that, for example, obesity is a big contributor. So, these new newer medications like the GLP-1 receptor agonists, and the incretin therapies, they're very exciting. They're contributing to weight loss. They're helping patients feel better. They're helping patients stay out of the hospital. And so, it's an exciting time in that secondary prevention space, particularly for patients who have HFpEF, but also HFrEF as well.

And then, the final piece is the tertiary prevention. You know, as a heart failure cardiologist, my goal is obviously to prevent this, but we have patients who unfortunately progress to stage C. They ultimately might need something like an LVAD or a transplant, so kind of heart replacement therapy. Those patients are just as important for us to consider those classic risk factors and be aggressive at treating them. For example, a patient with LVAD, making sure their blood pressures are well-controlled; patients with transplant, making sure that their diabetes, if they have it, is very well controlled. And so, across the spectrum of heart failure, from pre-heart failure to classic heart failure, to stage D heart failure, it's important for us to be aggressive with our management strategies to help patients fare the best.

Melanie Cole, MS: With quality of life being one of those main things that we look at and want to help the patient go through in that journey of primary, secondary, tertiary, all the way through to transplant or LVAD as you say, one of the most interesting things, Dr. Youmans, that I found about the statement is the importance of the language that are used. So now, we're not really wanting to say heart failure anymore because that word failure has that negative connotation to it, right? So, it's kind of taking the patient out of that positive space of looking at those risk factors stratification and those lifestyle behaviors and calling it heart function now and the impact of that patient-centric language. Speak about that a little bit because I find that fascinating.

Dr. Quentin R. Youmans: Absolutely. You know, I think it's one of the most important aspects of considering comprehensive and patient-centered care. You know, it's one of the most striking things when I meet a patient for the first time, they're coming into my clinic to establish with me. And I'm going through, you know, their whole HPI, understanding everything that's happened to them. And then, you know, at the end with the assessments, you know, you have heart failure, and just to see that patient's face drop. And so, many patients will say, "I hate that name. You guys got to change that name," you know, that comes up so frequently.

Melanie Cole, MS: I agree.

Dr. Quentin R. Youmans: And one of the shifts that we are recommending to make in the field is not a focus on failure, which means there's no hope, "Whatever you're recommending, I've already failed." It's a very past tense word. And instead, focusing on function. "There might be some limitations in the function of my current heart," but the goal of our recommendations-- and it's a very comprehensive, again, approach-- is to make sure that we can maximize and optimize the function of your heart.

And I think that shift is so important for patients because they recognize that they have some autonomy and some power to take control, to take control of their health, to take control of their heart function. And so, I think I'm very glad that we had that focus in the scientific statement. And I'm hopeful that that will continue to be permeated throughout the field.

Melanie Cole, MS: I agree. It's got that negative connotation when the patient hears that, as you just said. And right away, it changes their whole perspective on their condition and what they can do about it, right? So now, also the statement argues that within Cardiology-- and you and I were talking a little bit about this off the air-- that areas such as wellness, spirituality, resilience, wellbeing, nutrition, which we both know having studied back when we weren't really learning nutrition quite as much and its effect on the heart and on our wellness. These things still remain just a little bit underdiscussed and underappreciated, and that's my opinion. But the statement does talk about these things.

So, how does incorporation of these areas of wellness in your mind alongside those lifestyle modifications that we've been talking about kind of add to the future of comprehensive heart treatment, prevention, and wellness?

Dr. Quentin R. Youmans: Absolutely. I think it's a really important question. And I think it comes down to the fact that, you know, there's a lot of complexity in the human experience. And patients don't experience their disease processes in a vacuum. You know, there are certain things that patients lean on in order to optimize their health. And us as care providers, we need to understand what might be important for patients. So for example, that could be spirituality, that could be meditation, that could be so many different aspects of wellness that make a person a whole person.

And if we're going to provide the best care for patients, we need to consider all of these different aspects that are health-promoting. It can be very sad, you know, back to the conversation about failure, that can be a very hard pill to swallow. So, we need to lean on as much as we can, these actually positive attributes about patients' experiences and help them.

So, I think, it's a huge focus. It's something that we also need more science to understand the best ways to actually intervene in those spaces. But it's really exciting when we're looking towards the future, because we really are starting to recognize that understanding patients from a very complex and comprehensive approach is really important for patients with heart failure.

Melanie Cole, MS: And I think that also adds to that multidisciplinary collaboration. Because as we're looking at the wellness professionals and the dieticians that can help with obesity and diabetes and really all of your colleagues working together, that's the space as I see it, where this can come in. Just so important.

And looking ahead, Dr. Youmans, how do you see the technological advances, I mean, we're talking about wearables that can help keep track of not only steps, but blood pressure and all of these different wearables and then AI and incorporating that into clinical practice. So before we wrap up, I'd love you to kind of give us a blueprint for further research, what you see happening. But also important, what you hope will happen to bring all of this together.

Dr. Quentin R. Youmans: Absolutely. You know, I think the wearable space is really exciting. And one of the ways that it will help, you know, I just recently saw that one of the smart watches is going to be able to identify high blood pressure, for example. You know, there's some patients who know that they have disease, for example, they know they have hypertension. Then, the next step is to get them follow up, make sure they're on the right medicines, et cetera. There are a host of patients who have no idea that they have diabetes or they have high blood pressure. And so, there's a huge opportunity to bring patients in so that they can understand, you know, back to this primary prevention piece, if you don't even know you have the risk factor, how can you be focused on prevention? So, the wearables are going to be really exciting in identifying, hopefully, patients who have disease and then potentially even tracking those patients.

One of the really exciting things, you know, when we think about engaging patients in their care too, a little bit of gamification. And so, there's a lot of exciting research out there about how we can engage patients using wearables to recognize that they can, you know, maybe beat their walk, their steps per day this month compared to last month, for example. So, I think, there are going to be so many aspects of the wearable space that are really exciting.

You also mentioned artificial intelligence. That's obviously the wave of today and going to be the wave of the future. And I think one of the exciting things about AI is that it's going to be able to streamline a lot of the processes when it comes to identifying patients with heart failure. You know, there's a lot of studies looking at large language models to try to look in the EMR, for example, or other data sets to say, "Hey, this person is out there in the community. It seems like they may have heart failure." And then, we can get them into access care potentially. But then, also streamlining things like our work processes. You know, as clinicians, we know we're all stressed for time, and so how can we offload some of that to AI to help to maximize and optimize care for patients. I think, that's a really exciting space that has a really bright future as well.

And then, you know, to your last point, just about bringing it all together, I think prevention has to be the key. You know, it's great that we have the opportunity to help patients and potentially help them live longer with LVAD and heart transplant. It's a really exciting day when we can say, "Hey, somebody's on the transplant list, and we can give them a heart." It's equally and even more exciting when we can prevent them from getting to that point to begin with. Recognizing that it starts with the primary prevention, identifying those risk factors if we can, really being as aggressive as possible at treating those risk factors if they do come up, and then thinking about this new paradigm: the CKM, cardiovascular, kidney, metabolic. I think that paradigm, and again, to your point about being a very collaborative approach, recognizing that we can engage with Endocrinology, with our PCPs, with our cardiologists, with our nephrologists, bringing everyone together to understand what the risk factors are that patients are going through, and how can we optimize our care in a collaborative fashion. That's going to be the key to prevention, and that's how we help the most patients.

Melanie Cole, MS: I agree with all of this, Dr. Youmans. And it's such an exciting time in your field and such an exciting time in heart failure prevention. We're learning more all the time. I thank you so much for joining us today and sharing your incredible expertise. This was really such an enlightening discussion. Thank you again.

And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.

Dr. Quentin R. Youmans: Thank you.