Joey Wahler (Host): There can be many misconceptions about it. So, we're separating heart failure myths from facts. Our guest is Norma Velasco-Flores. She's a nurse practitioner and a heart failure clinic advanced practice provider at UM St. Joseph Medical Center. This is the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. Thanks so much for joining us. I'm Joey Wahler. Hi there, Norma. Welcome.

Norma Velasco-Flores, DNP: Good day. Good day to everyone, and thank you for the opportunity.

Host: Absolutely. We appreciate the time. And so, let's jump right into it here. One myth is that heart failure means your heart has stopped working. So, what does it really mean?

Norma Velasco-Flores, DNP: In my practice, when I see patients coming to the clinic, there is a barrage of emotions coming in. Whether it's anger or guilt, but the greatest of them is fear. And I guess this is coming from this myth that "My heart has stopped working. What will happen to me? Will I die?"

So, what heart failure means is that it is a complex of clinical syndrome or symptoms or signs, mainly shortness of breath when you exert, swelling in your leg. You cannot lay flat when you sleep. And all of this comes from the heart's inability to pump blood effectively or to relax effectively due to either functional or structural impairments.

And when we talk about heart failure, we always have to mention ejection fraction. This can be measured in an ultrasound of the heart or an echocardiogram, and it shows how much blood leaves the left ventricle with each heartbeat. And on that note, there are different types of heart failure, depending on the ejection fraction. We have heart failure with preserved ejection fraction, meaning you are on the normal ejection fraction range, which is 55-70%. The heart is pumping effectively, but it is stiff. And then, we have something that is called a weak heart or heart failure with reduced ejection fraction. And in terms of number, the ejection fraction is 40% or below. And we have somewhere in the middle, 41-49%, which is called heart failure with mildly reduced ejection fraction.

Host: All right. Well, I'm sure that many of those joining us are relieved to find out that information. How about our next myth? Namely, people with heart failure should not exercise or be active. So, is it safe? And what activity, generally speaking, Norma, is recommended?

Norma Velasco-Flores, DNP: Yeah. So, physical activity and exercise training are foundational to heart failure prevention and preventing progression of heart failure to those patients who already have established the diagnosis. So, we have evidence from randomized controlled trials that exercise training improve quality of life. It improves exercise performance, their functional status in both patients with the reduced ejection fraction or the preserved ejection fraction type of heart failure. And it also increases the oxygen delivery to your muscles.

So, the guideline actually is moderate intensity exercise. And when you define that, it's about 150 to 300 minutes of aerobic exercise in a week. And how do you define moderate intensity exercise? So, you have to reach 50-70% of maximum predicted heart rate. And how do we go even more detailed than that? We have this magic number of 220. You subtract your age. And then, 70% of that is your heart rate that you would want to achieve when you do your aerobic exercises.

Host: Gotcha. Well, I will leave mathematical equations like that to professionals like yourself. Next myth, heart failure patients must completely cut out salt and also fluid. So, what's the truth here about diet restrictions?

Norma Velasco-Flores, DNP: Yeah. I always remember this patient who came to me, and she even had this cookbook of low sodium diet. I even took a picture, but I think she overdid it, because later on she came by with seizure and a fall, and she was admitted in the hospital because of extremely low sodium diet.

So having said that, sodium is a very important component of our electrolytes in our body. You can have serious neurological complication if you don't have sodium. In heart failure, we wanted to limit. The magic number is 2000 milligrams or 2 grams of sodium. So technically, we teach our patients to read food labels, avoid processed foods, fast foods, canned foods, avoid cooking in soy sauce or fish sauce, those kind of things.

And with regards to fluid intake, we have this very recent study. Actually, it was presented in the American College of Cardiology Scientific Meeting in Chicago this last march. And the study's called FRESH‑UP. And they found out that there's no difference in terms of safety for those patients that are limited with fluid intake, and those that have liberal fluid intake. And as a matter of fact, the medications that we give to patients now can cause dehydration and side effects of urinary tract infection. So, I actually teach them to hydrate themselves , at least two liters of fluid, mostly water.

Having said that, there is a caveat though. If your serum sodium or the sodium in your blood is low, and then you have more fluid on board, then you have to be more careful about your water intake. So, there's a caveat there. And then, also, if you are on end-stage kidney disease, then you have to consult your nephrologist regarding that.

Host: All right. And speaking of medication, which you touched on there, our next myth: Medications only mask symptoms but don't actually help the heart. So, that said, what impact can meds have on heart function and quality of life here?

Norma Velasco-Flores, DNP: Actually, this is one of my favorite topics when we talk about heart failure, the medications. And I always correlate it with what happens in your heart, in your body when you have acute heart failure. So initially, the body will try to regulate in order to compensate, and we call this neurohormonal activation.

 It's okay in the beginning, but persistent or prolonged neurohormonal activation can actually damage your heart. It can result to progressive fibrosis or remodeling wherein the heart becomes boggy, dilated, bigger, And the left ventricular ejection fraction decreases. And for example, patients have good functional capacity, I don't have much symptoms or low symptom burden, this remodeling process changes. Negative effects happens to the heart. So, the action of the medications now prevents this deleterious or harmful effect of neurohormonal activation to the heart. And currently, we have the foundational for guideline-directed medical therapies. These are your beta blockers. These are your mineralocorticoid antagonist. These are your renin–angiotensin–aldosterone inhibition and we also have added more recently the sodium glucose transporter inhibitor. So, all of this act in order to improve your heart function, improve the quality of life of patients.

Host: Well, let's talk now about age a little bit. Because our next myth, heart failure only affects older adults. So, can younger people develop it? And what are the risk factors?

Norma Velasco-Flores, DNP: In the recently concluded Heart Failure Society of America Conference in Minneapolis, they have presented this heart failure stats. It's called Heart Failure Epidemiology and Outcome Statistics, and it is actually available in the Heart Failure Society of America website. So in this, they found that there is a greater impact of heart failure to younger individuals. So, there is a proportion of patients age 35 to 64. This proportion have even showed an increased mortality or death in this patient population age.

Host: Myth: Diagnosis of heart failure means the end is near, Norma? Say, it ain't so, as they say, right? So what does that prognosis look like today and how has treatment improved outcomes?

Norma Velasco-Flores, DNP: Yeah. And actually I just wanted to add that in that statistic, we have increased the risk of heart failure in our lifetime. So, there is a 24% chance that You can have heart failure. So, this means that approximately one to four persons will develop heart failure in their lifetime.

But as I've said, we have established this pillars of medical therapy that helps improve the heart function, improve the quality of life. So having said that, medication adherence, lifestyle modification, regular medical follow up really increases the chances of a very good prognosis and prolonged quality of life. Having said that too, we are talking about the risk factors so we can mitigate the risk factors. These are hypertension, obesity, sleep apnea, to name a few.

Host: Next myth, and we're cheating a little bit here, Norma, because you've already answered this to some degree. But I think it's important to punctuate the point, there's nothing you can do to prevent heart failure. You've already touched on the fact that lifestyle changes and early intervention can help lower the risk. So, how do professionals like yourselves get that point across?

Norma Velasco-Flores, DNP: Yeah. So, I always discuss-- and again, this could be a little bit book-based, but I always discuss the patient so they can understand too that there are different stages of heart failure.

When you say stage A, you have the risk factors, the one that I mentioned, hypertension, obesity, sleep apnea, to name a few. And with that, you still don't have the structural abnormality in your heart when you do the echocardiogram or the ultrasound of your heart. You don't have structural abnormality, but you have risk factors. And so, we have to mitigate that. And then stage B, meaning you have the risk factors and you have the structural abnormality, but you are not showing the clinical symptoms, you're not clinically in heart failure. And then, stage Cs, actually, this is the biggest bucket of patients that are diagnosed with heart failure. So, they are the ones with the structural abnormality. We know they have the comorbidities, and we know they have the clinical symptoms of heart failure. And then, we have the stage Ds. And these are the patients that are refractory. They have an advanced stage heart failure.

Host: So, I want to ask you about one final myth, namely, there are no recent advancements in heart failure care. And so, what are the most exciting developments you can share with us that give patients hope for the future?

Norma Velasco-Flores, DNP: So, we are actually living in a more exciting time in Cardiology. We have a lot of randomized control trials lately. And the American College of Cardiology, the Heart Failure Society of America, the American Heart Association are all working together in order to get this message across the population, across the community, or even across the world.

As I've said, now, we have the four pillars of medical therapy. We have our MRAs, we have our renin–angiotensin–aldosterone system. We have our SGLT2 inhibitors. We have our beta blockerS. These are now the staples, and we know that this have good effects in terms of functional capacity, in terms of the left ventricular ejection fraction to our patient. And not only that, the diagnostic process has improved tremendously. And because of that, even the rare cardiac diseases are now being diagnosed. And we even have novel treatments for them. For example, for cardiac amyloidosis, we now have our silencers and stabilizers and treatment for polyneuropathy.

These are all part of heart failure, even in hypertrophic cardiomyopathy, when in the past, we only rely on surgery or beta blockers. But now, we have cardiac myosin inhibitors even in the treatment of heart failure with preserved ejection fraction. We even have established treatment for that. We have the non-steroidal mineralocorticoid antagonist, which they have recently released for treatment of heart failure with preserved ejection fraction and mildly reduced ejection fraction. We even have better use of our devices, our pacemakers, our cardiac resynchronization therapies. Gene therapy is coming on the way. So, we have a lot of advances now in the world of cardiology. Prognosis is good. Future is looking very good.

Host: I'm sure those joining us are both relieved and thrilled to hear those words. Folks, we trust you're now more familiar with heart failure myths and facts. Norma, thanks for doing such a wonderful job of separating the two. Keep up all your great work and thanks so much again.

Norma Velasco-Flores, DNP: Thank you.

Host: Absolutely. And you can find more shows just like this one here at umms.org/podcast, as well as on YouTube. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Live Greater, a health and wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again.