Transcription:
Managing Congestive Heart Failure

Prakash Chandran: Congestive heart failure is a chronic condition or the heart does not pump blood as well as it should. While it's a serious condition, people who have it can learn how to manage it. We're going to talk more about it today with Dr. Neel Khanna, the Medical Director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall.

This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall. My name is Prakash Chandran. So first of all, Dr. Khanna, thank you so much for being here today. I really appreciate your time now. I kind of gave the textbook definition up at the top, but I'd love for you to talk more broadly about what congestive heart failure is.

Dr Neel Khanna: Sure. Congestive heart failure to me is a clinical diagnosis based on the symptoms that the patient presents with, which is basically congestive symptoms, meaning the term comes from congestive symptoms in the lungs, meaning that for whatever reason, there has been backup of fluid from the heart into the lungs. And it's caused some problems with breathing, getting good oxygen intake and general functional status of the patient.

Prakash Chandran: Okay. And so when we say that congestive symptoms, I understand that it's a patient by patient basis, but is there a common picture of what someone with congestive heart failure looks like?

Dr Neel Khanna: Yes. Typically, there are two types of heart failure or congestive heart failure, but both cause the same symptoms in the sense that the lungs are congested. Patients typically have poor exercise tolerance. They may have signs of what we call volume overload, meaning their body is struggling to keep up with the amount of fluid volume. So they may have swelling in their ankles, swelling in their legs. They typically have a problem with lying down flat because there's some fluid in their lungs. And they may often notice that there's distended veins in their neck that indicate that their veins are distended because there's too much fluid in the body.

But there are two causes of this. One could be systolic what we call heart failure, which means that the heart is weak, which is what you spoke about earlier, where the heart is weak and it's becoming overburdened because it's weak. The second type of heart failure that there is, is called diastolic heart failure. Like I said, it causes the same congestive symptoms, but the heart is not actually weak. It's pumping at its normal strength if we look at it, but it's relaxing too slowly, which causes a pressure build up in the heart and the same congestive symptoms. Both these types of heart failures, systolic heart failure and diastolic heart failure, cause pretty significant morbidity and mortality in heart patients, and often have to be treated aggressively and in similar ways.

Prakash Chandran: So today, we're talking about managing congestive heart failure. What does that mean? I know you mentioned there's poor exercise tolerance. I know that there are a number of different things that people with congestive symptoms cannot do, but can you talk about at a high level what management looks like?

Dr Neel Khanna: Yeah. And I wanted to focus on at-home management that patients can do. In the hospital, first we'll talk about what your physicians and your cardiologists will be trying to do, is to basically drain out this excess fluid that's giving you the symptoms of leg swelling and fluid in your lungs. And we do this with special medications called diuretics, which help patients urinate out excess fluid and sometimes the kidneys and the heart need that extra push with these special types of medications so that they can Get the body and the heart better into equilibrium and get out the extra fluid and patients often feel much better, much quicker.

There's other ways also in controlling the blood pressure, because the better your blood pressure is controlled, the better the heart can function and the easier it is to get these congestive symptoms better. The primary take home is for patients who want to manage their heart failure at home, which is the goal of all of us cardiologists to get patients to a point where they can manage their disease well at home, until it reaches a point where they need our expertise.

But the main way that they manage this is by keeping an eye on key factors. Number one, what their weight is. When people start to retain fluid and go into congestive heart failure, they will notice that their weight goes up sometimes two pounds a day in the excess category going higher, whereas they're not eating much more. That is likely because their heart is failing and they're starting to retain a lot of fluid because the heart is a pump and it's not able to pump out the fluid like it's supposed to.

They also have to manage with their diet. High salt foods will hold on to a lot of fluid and will cause an increase in congestive symptoms for patients. So simple things is just keeping an eye on their weight and watching their diet very closely and managing the amount of sodium, for example, that they take in their diet can really help them manage their congestive heart failure at home.

Prakash Chandran: Yeah. So those are the key factors to look out for, weight and diet. Now, something in the hospital that you mentioned was taking a diuretic to basically urinate out the excess fluids. Are there any at home diuretics that people can take to do that?

Dr Neel Khanna: Actually, most of the in-hospital diuretics that we use have an at-home counterpart. Namely, the at-home counterparts are oral medications. Obviously in very rare cases of end-stage heart failure, we send patients home with an IV line so that they can get IV diuretics. The benefit in the hospital is if patients have reached a point where their medicines are not working anymore, then we can give them the IV medication and the IV diuretics that get the fluid out very quickly and are very effective.

At home with oral diuretics, patients often if they take care of their risk factors, watch their fluid intake and watch their salt intake, they can do very well with pill diuretics for a long period of time. What I do have to say is that there often reaches a point if patients are not as responsible with their diet or their fluid intake, or if they're just decompensating for another reason, like poor blood flow to the heart, for example, then the oral pills may not work anymore. And so, because there's a retaining a fluid, it's retained in the stomach and the gut also. And they just don't absorb their pills as well anymore. So often my patients will come to me and tell me, you know, "My weight continues to go up every day and I'm taking my pills every day. And even one day I doubled up on my oral diuretic and it's still not working." And that's a red alarm to a cardiologist and to me to say that maybe they have kind of gotten off the curve to a point where the oral pills are not working anymore and they may need to come into the hospital to get the IV medication so that it can go straight to the kidneys and straight to the heart to help get rid of this excess fluid.

But the hallmark of that is having a patient who's well-informed, who understands what the medication usually does for them and what the diuretics usually do for them and their blood pressure medication. And recognizing that it's not doing what it usually does when they're doing well. And so a patient has to be very well-informed to understand that and see those trends.

Prakash Chandran: Yeah, that makes a lot of sense. So another thing I wanted to ask is if they are managing this at home, how often or what kind of cadence should they be coming into the hospital just to get checked up, whether it be that direct line diuretic to drain out the excess fluid, or just to check up on things?

Dr Neel Khanna: In hospital as an inpatient, our goal is always never. You know, if we could manage patients at home with their heart failure, it's always better. We're always happier that way, because obviously if you come into a hospital, there are other risks, especially in the modern era with COVID-19 infection. So our goal is always to have patients well managed at home. And if we have them on the right medications and they're watching their fluid intake and their diet and their sodium intake, and they're having regular exercise so that they have good circulation of these medications in their blood, they may never need to come as an inpatient to the hospital. And that's always the goal.

Now, as an outpatient to our offices, that's a totally different story. Whereas a lot of cardiologists for their systolic heart failure patients, meaning patients who have a weak heart, they may have their patients come in once a month to have them evaluated, to make sure they're not retaining fluid, to check certain parameters in their blood, such as their potassium to make sure the medications are working effectively, so that may be as much as once a month. It really is determined by how on top of their medical care the patient is and how severe their disease is. Congestive heart failure is a spectrum, and there are some patients who are very fragile and whose heart is very weak who need very close followup, even if they're very attentive to their medical condition just because their heart is weak enough where any little thing will tip them over the edge. So it really varies on the patient, but our goal is to keep patients with congestive heart failure out of the hospital inpatient setting and to have them more managed at home and in the office.

Prakash Chandran: Now, as we start to close, I wanted to ask if someone is listening with a friend or family member with congestive heart failure, do you have any recommendations for them around helping that friend or family member manage things?

Dr Neel Khanna: Yeah, support is key. And often, especially in advanced disease and advanced heart failure, you really do need someone to help you with your medication and help you get around. It is really key, But my take home to family members and to those patients are, number one, make sure you have a scale in your house. Get very familiar with your weights. Get very familiar with your diet and what you should be eating. Also be familiar with really restricting your salt intake and getting good at counting sodium intake in your food because it's extremely important and sodium is the number one off-setter of heart failure.

And number three, make sure you know your medication in and out. Because for patients with significant heart failure, congestive heart failure symptoms, even missing one of their blood pressure medications for one day can totally offset the balance that they have built in their heart and can set them off. So manage your weight, measure your weight daily if you have significant heart failure, count the amount of sodium that you're intaking in your diet. Keep your diet relatively stable and keep those salty meals to a minimum.

Prakash Chandran: That is extremely good advice and a good framework to follow. anything else that you want to share with our audience before we close, Dr. Khanna?

Dr Neel Khanna: I just want patients to know that congestive heart failure is one of the leading causes of hospitalization in America and of morbidity and obviously we know mortality. But it really is a disease that can be curved and slowed down if you have really attentive family members and patients. So I know my patients who do the best are the patients who really know their body well, know their medications well and know their symptoms well, so that if they see something, they can predict it and bring it to my attention before it actually becomes a problem that they have to go to the hospital for.

Prakash Chandran: Well, Dr. Khanna, thank you so much for your time today. We truly appreciate it.

Dr Neel Khanna: Thank you for having.

Prakash Chandran: That was Dr. Neil Khanna, the Medical Director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall. Thanks for checking out this episode of Doc Talk. You can head to montefioreslc.org to get connected with Dr. Khanna or another provider. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

My name's Prakash Chandran. Thanks again for listening and be well.