Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips on navigating medical decisions and building a healthier future. Today, I'm sitting down with cardiologist Dr. John Rommel and we will be talking about heart fit. Dr. Rommel, welcome to the show.

Dr. John Rommel, MD: Thank you for having me.

Michael Smith, MD (Host): Before we start, I always love to ask the doctors always this, right? I'm a doctor too. I went through all that residency. You got to make a decision what you want to do with your life. Why did you want to become a cardiologist?

Dr. John Rommel, MD: It's funny. I got into med school through one of those continuum programs out of high school. So I was in med school, from high school on, and I kind of fell into it, right? I went through, got into my third year of medical school, and said, did a cardiology rotation. I think I was just blown away by what cardiology offered. It gave you such a diverse group of patients that you can see. You had acute care, you had longitudinal care. And you had a really fascinating way to evolve your career throughout that field. And so, what you found interesting at 26, might not be as interesting to you at 56, but you had something else you could change into. And I thought that was just so cool to see that world of cardiology just ever changing.

Host: Fantastic. We're going to talk about congestive heart failure. And I think right off the bat, give us your standard, solid definition of what congestive heart failure is. And I also want to ask this with that, is it curable? Because that's what a lot of people want to know.

Dr. John Rommel, MD: Yeah. And, you know, in healthcare, we use a lot of different terms, I think, to describe heart failure. The best definition, the official definition that I always use is it's the heart unable to meet the metabolic demands of the body at normal filling pressures.

What does that really mean? I think it's best said by one of my mentors who says, we have all these fancy terms, but you know it when you see it, right? The heart just can't keep up. And so patients get swelling, they get short of breath, they get tired doing daily activities. And to your point, unfortunately, it's not curable.

There really is no cure for heart failure. We have a lot of different treatments and strategies to try to help mitigate it and manage it and help our patients live the best lives they can, but at the end of the day, they will have that for the rest of their life.

Host: Understood. And I know there's a lot of research, I know that's going on to hopefully someday make it curable without a heart transplant at the end of the day. So let's talk, you know, when you look at congestive heart failure as a physician, I know you kind of look at them as like mild, moderate, severe, right?

So if we talk about mild and moderate, now we're not going to get into the classes and all that kind of stuff, but just mild and moderate. What are the treatment options for those patients?

Dr. John Rommel, MD: So, over the last few years, we've really been focusing on our guideline directed medical therapy for those patients, right? Really in the last few years, we've kind of shifted to this mindset of what we call the four pillars of heart failure. So getting them on a little bit of a few different categories of medicines like aldosterone antagonists, like beta blockers, like, ACEs, ARBs, or things like Entresto, and more recently, the biggest push for us has been to focus on trying to get patients on SGLT2 inhibitors. The medicines that were initially diabetic drugs, and now we're just finding really have benefit across the spectrum outside of diabetes in the world of heart failure. And our mindset is for these patients with mild and moderate diseases; really start to focus on getting them on good therapy and then making sure you're treating as much as you can the underlying cause, right?

If they have coronary disease, making sure that's being treated. If they have rhythm issues, making sure you're treating that, looking for some of the rarer causes to make sure there's nothing else we need to be doing aggressively for these folks, even if their symptoms are mild.

Host: So a patient listening to this, or, maybe someone has a family member, even a family practice doctor, when you say that there are, diabetic drugs that now have been shown to help in heart failure, people might be like, but I'm not a diabetic, or maybe they are and they need it anyways, but many of them, maybe they're not.

So how do you answer that question? This drug is designed for a diabetic. Now you're saying I can take this with heart failure?

Dr. John Rommel, MD: Yeah, and I think the honest and full transparency, I think we're going to see more and more of this. As some of the newer diabetes drugs again right now in the last few years are showing benefit in the world of cardiology and heart failure. I think the honest truth is you have conversation with the patient.

You try to talk as much as you can about how the drug is effective or why we think it's effective in heart failure, not just in diabetes. You reiterate, yes, you don't have diabetes. This is for heart failure. And you just try to meet them where they're at in their understanding of medicines and disease to try to help them kind of figure out why this medicine might be beneficial for them and why taking yet another medicine might still help them do the right thing for them.

Because obviously everyone's a little hesitant to take extra pills if they don't need it, but we can sit down and say, no, this will help you live a better, happier, less symptomatic life.

Host: I think you just nailed it right there, Dr. Rommel. At the end of the day, if you can tell somebody that if they take this, the studies show you're going to feel better. You're going to walk more, right? You're going to go to the store without getting so short of breath. So I mean, right there, they're going to buy into that because you're talking about what they're going through.

So I think that's fantastic. Now, unfortunately on the more severe end of this, I mean, we know advanced heart failure, I mean, it impacts their entire lives. What can we do for those patients? Is there, is there something new going out? There's something new on the horizon. How do we help them?

Dr. John Rommel, MD: Yeah, and I think this is an ever evolving field, right? Patients with significant heart failure symptoms, despite getting on guideline directed therapy, you know, in the last few years, there's been a lot of attention placed on making sure that their valves are stable and thinking about that. Making sure they're not having too much regurgitation or leakiness of their valves.

I think there's been a lot of talk recently and a lot of focus recently on some novel devices coming down and coming into the healthcare system, like the Barostem device which can help stimulate the carotid nerve, help regulate the sympathetic and parasympathetic tone. And these are devices that I think we're still trying to sort out exactly where they fit into our mindset.

But if patients really start to cross into the advanced heart failure category, you know, where clearly medicines are no longer effective, we still have about three major things we think of for them, right? We think about heart transplant, as we talked about earlier, which unfortunately, it's still a very limited commodity in the world.

We think about left ventricular assist devices, like the HeartMate 3. We think about palliative inotropes, things like dobutamine and milrinone. And then, the honest truth is within that, if they're truly at advanced heart failure, we also need to be having a conversation about what this means for their life expectancy and symptom management as well, too, and making sure that's just as much of our conversation as any device or thing coming down the road.

Michael Smith, MD (Host): It seems to me then, for you, as a cardiologist, I was a radiologist, you're the heart guy, . Obviously, one of your main goals for any patient then is to make sure they don't advance or they slowly advance to that stage. I mean, that makes sense. So when you look though, then at those patients who maybe have the more milder cases, maybe moderate, what's the future for them? Do you see anything promising on the horizon in terms of research, medicine, whatever it may be that may prevent them going to that advanced stage?

Dr. John Rommel, MD: Yeah. I think it's a fascinating time to be in the world of heart failure, right? You know, between, that was at 2005 and 2015, we essentially had no drugs come to market to help and stabilize and benefit our patients. And from 2015 on, it just seems like the forefront of research just continues to evolve.

 For our patients where they're at right now with mild symptoms, you know, a lot of our research is again, focusing on getting them on good guideline therapy. There are new devices coming out. We touched on some of the sympathetic tone or parasympathetic tone stimulators earlier, but you know, there are other therapies in phase two and phase three studies right now that target just different parts of that RAS inhibition pathway, that connection between the heart and the kidneys.

 What we're starting to see is by getting people on a little bit of all these meds that block those pathways at different locations; we stabilize the heart function just a little bit better, stabilize that patient a little bit more, and try to help that progression from occurring as a result.

Host: The body is complex, right, Dr. Rommel? It's not, when we think of heart failure, we tend to think, okay, what's that one thing we can do to treat it and be done with it? But it often, as we discover in medicine, many things are multifactorial and a lot of your approach has to be multimodal to those different factors.

So yeah, you're right. I think this is a fascinating time to be in your field. Now, if you were to ask the average person just walking on the street, if you were to say, what is cardiorehab for? 99 percent would say, oh when people have heart attacks. Not true, right? Heart failure people, or patients, can also benefit from that, right?

Dr. John Rommel, MD: Absolutely. And we've seen that, right? You know, so cardiac rehab is 100 percent not just for the folks who have just had heart attacks. It is for our patients with heart failure. We have seen multiple studies now demonstrate patients with heart failure go to cardiac rehab, see improvement in their functional ability, see improvement in their quality of life.

And actually here in Wilmington, we are actually lucky enough to have an intensive rehab, cardiac rehab program as well as a traditional rehab program. Both are fantastic, but that intensive rehab program really also focuses on meditation and diet and working with a patient from a whole body perspective.

And by doing that, we've just seen a lot of our patients who embrace that aspect of their health really transform themselves and see their functional ability improve without, in addition to taking their medicines as they're supposed to, but it takes, as you pointed out, it takes everything.

So for our folks that have gone to cardiac rehab and embraced it, we really see they're feeling better, living longer, doing better from embracing not just the medicine side, but again, everything they can do for themselves.

Host: Fantastic. It's great to see that cardiac rehab is now not just getting on a treadmill for five minutes or something, right? Hey, when I went through medical school, that was about it. That's kind of what it was, right? It has expanded, as you say, more holistically, and it's great to see that. A lot of good studies showing that meditation lowers blood pressure, makes people feel better. All that. So fantastic. Now, Novant Health

 has a palliative care clinic, right? Tell us a little bit more about that. Cause I think that's where you're working at. Right?

Dr. John Rommel, MD: So we work hand in hand with our palliative care colleagues as well. In Wilmington, we opened up our first outpatient palliative care clinic for cardiology in one of our heart failure spaces. And I think this goes along with thinking about that patient, all of the patient, right. And not just from their heart and the medicine standpoint, but again, that multimodality standpoint. And what we realized with heart failure, for everything we've touched on earlier, that it's a disease that we're not curing at the end of the day, that for a lot of our patients, it's a disease that gets worse, they get more symptomatic over time.

I think thinking about it from a palliative perspective,is important. It's making sure that our patients symptoms are being addressed. It's making sure that our patients goals beyond just getting placed on medicines are being addressed. And, and I think that can be tough sometimes for patients to come in and say, what, what do you mean?

You know, you want to send me to palliative care, but I'm doing okay right now. And you have to talk to them and say, this isn't about, right now, necessarily. Yes, you are doing okay right now, but this is a progressive disease. Making sure we're talking about it from every angle and every aspect is important.

And we've seen the literature again on that show that patients that engage in palliative care sooner, do better. Their families are more informed. They get better results from a symptom standpoint. And at the end of the day, I think everyone's a little bit happier by again, taking that approach and that whole patient approach, not just thinking on their individual organ.

Host: Fantastic conversation, Dr. Rommel. I have two more questions. The first one in the end here is, prevention is always best, right? Let's not get heart failure. I mean, that would make this all easy, right? So, and I don't mean to put you on the spot, give me your top three, lifestyle things. What, what are the top three things you believe people can do to prevent this from happening at the get go.

Dr. John Rommel, MD: Yeah. So, you know, I wish I could say I had some secret answer to all of this that nobody's ever thought of before. I think the big things are the things we all know that we need to do and we all need to focus on, right? It's eating right. It's trying to avoid processed foods. It's trying to eat vegetables. It's trying to eat healthy. It's exercising. It's avoiding smoking. It's making sure you're controlling your other medical problems if you have them. And I think also making sure you're talking to your providers, right? To your cardiologist, to your primary care provider, just making sure you're telling them about your symptoms and keeping that radar up, especially if you have a family history of heart failure to say, okay, is this a sign I might be developing it?

Host: Healthy lifestyles, good sleep, good food, exercise. I mean, it's not cliches. It becomes cliches, but it's not, it really is the reality of things. To wrap up, what is one last thing you'd like the audience to know?

Dr. John Rommel, MD: As I tell my patients when they come in to the office, right, you know, I say to them, heart failure is a big deal. You know, we sit down and we have our first conversation together. And, you know, I say, but when you walk out the door, I don't want you to think just because you've been told you have heart failure that all hope is lost.

You know, we're here for you to be a team and it's going to take all partners in this. It's the patient doing their part. It's exercising, eating right, taking their medicines. It's your heart failure team getting you on the right medicines. It's our nurses making sure that your fluid levels are staying stable. It's our pharmacists making sure you can get our medicines.

It's our palliative care team, making sure your, your goals are being met. And then talking to our patients and saying, you know, and then if things are getting worse, despite our best efforts, let's have a frank and honest conversation about what those next steps look like for you. And let's try to plan the best we can, acknowledging that we don't know the future, but at the same time, we can try to be good stewards of what we think might be on the horizon.

Host: Fantastic summary. Dr. Rommel, great conversation. Thank you for joining me today. To find a physician, you can visit novanthealth.org or for more health and wellness information from our experts, visit healthyheadlines.org. I'm Dr. Mike, thanks for listening.