Transcription:
Treatment Options for Heart Failure

Melanie Cole: Welcome to the show. Our topic today is heart failure and my guest today is Dr. Eugene Chung. He's an invasive cardiologist and nationally recognized heart failure specialist with the Christ Hospital Health Network. Let's start with a little background on heart failure and how is it classified.

Dr. Eugene Chung, MD: Heart failure is a very common condition. In fact, it’s still is the most common condition for which patients over the age of 65 are hospitalized. It’s possibly one of the most expensive problems in the healthcare system. It’s a major issue socially, medically and economically. Heart failure has evolved over the last 20 years. I think the reliance on the pumping strength or the ejection fraction of the heart has changed to the point where heart failure has become more of a symptomatic or a clinical syndrome, which is characterized by shortness of breath, volume retention, generalized fatigue and inability to perform activities of daily living, and not as reliant on the heart’s ejection fraction. What I'm getting at is the fact that about half of our patients with heart failure actually have a heart function that’s normal in terms of contractile strength. The problem is often something else. It’s a little stiff, it can't relax very well, it doesn't fill very well, there are issues with valves and blood pressure that contribute to heart failure, and kidney dysfunctions. There are multiple reasons why people might develop heart failure not just simply based on the weak strength of the heart.

In that regard, heart failure can be classified broadly as patients with heart failure syndrome, which is comprised of symptoms and physical findings but broadly classified as those with a normal ejection fraction and those with abnormal ejection fractions. The ejection fraction is the percentage of the blood that's in the heart that is squeezed out with each heartbeat. Normal is about 55% to 60%. Anything below 50% would be considered abnormal. You can broadly categorize patients into those two categories.  

Melanie: Are we looking at this as a chronic condition now that is managed as opposed to attack as an acute situation?

Dr. Chung: That's a very interesting feature of heart failure. The heart failure patient typically is a chronic patient. It's a chronic disease. Outcomes have really improved over the last 20 years with medications and devices. However, there are episodes of decompensation during which the patient has an acute presentation. Categories of a heart failure condition are chronic, acute the first time and acute on chronic or someone presents with an acute decompensation in the background of chronic disease. This is a chronic disease that episodically flares up as an acute condition.

Melanie: How important is early diagnosis being crucial to improving the outcome prediction if you're looking at things like low oxygen saturation if someone is breathless or suffering from edema? This needs to be diagnosed pretty quickly. What are some valuable prognostic tools you're using to figure this out sooner rather than later?

Dr. Chung: That's also very important to pick things up before they become decompensated so that you can make adjustments to help patients avoid hospitalizations and major decompensations. Picking up a risk that is going up is very important because every hospitalization is associated with worse outcomes. Avoiding hospitalizations is imperative for heart failure patients. When we talk about picking up symptoms of decompensation early, before it becomes acute on chronic, the way we manage patients has shifted further to the left so that we can pick people up before they present. The old model would be ‘Mr. Jones, tell us when you're starting to get short of breath and if your weight is going up, call us or come to the office or the hospital.' It's a method that has led to suboptimal outcomes. Patients develop weight gain, fluid retention and symptoms as the very last step before entering the hospital. Before that, 10 or 12 weeks before, patients start developing signs and symptoms that are very subtle but can be picked up by more sensitive measures.

For example, the pulmonary artery pressure, these are the pressures in the lungs that go up well before patients become symptomatic or they start to retain fluid. Typically, there's no way to pick that up. There may be ways to do it on a wider basis by using things like cardiomems, which is a little sensor that we implant in the lungs and the patient sends a transmission once or twice a day by lying on a pillow and pushing a button. The pressure in the lungs is then transmitted over the Internet to our telephones into our computers and we'll be able to see if someone's pressures are going up, which is the hallmark of a patient who's starting to go back, and then before the patient actually gets admitted to the hospital, we can actually make interventions. This is a way to remotely monitor patients so that their disease progression is picked up well before they even know it. I think that’s where the future is going to be able to pick people up remotely so we can intervene before they end up decompensated.

Melanie: Intervention, whether somebody is inpatient or at this point it's been diagnosed and they are outpatient and you're managing it, start with pharmacologic or medicational intervention. What would be the first thing if you've been using cardiomems and you've watched all of this stuff, now what are you doing medicationally?

Dr. Chung: The first priority for patients and physicians alike in heart failure is symptom control. Typically, symptoms of heart failure revolve around shortness of breath and fluid overload or too much volume. The goal of initial treatment is symptom control and that usually starts with diuretics like Furosemide or Torsemide. These kinds of diuretics are very effective at removing intravascular volumes so that pulmonary congestion and pulmonary hypertension are resolved and symptoms improve. Other things might be blood pressure control to allow that to happen, but basically, the initial goal of therapy in the acute setting is symptom control. Beyond that, what is also important is to modify the course of the disease. The inevitable course of heart failure is to get worse. Whether it gets worse in spurts or gets worse quickly or slowly is dependent on patient factors but also interventions. There are multiple medications that might be useful in a patient with a reduced ejection fraction such as ACE inhibitors, ARBs, and Spironolactone, now the most recent drug Sacubitril and Valsartan, which is also known as Entresto. Furthermore, there are beta blockers that have been tested extensively. These are drugs that can modify the course of the disease and slow down progression, reduce mortality, and improve quality of life. These are the pharmacologic intervention that would come after the initial step of symptom relief.

Melanie: When does it become surgical? If you’ve tried the pharmacologic interventions and you said your first goal was symptom relief and management, when does it look to something whether it’s LVAD or valve replacement, whatever it is when that does come down the pike?

Dr. Chung: After the initial interventions that include symptom relief and disease-modifying medications, the next step before we get to surgical considerations would be device therapies like pacemakers and defibrillators. Defibrillators in patients with low ejection fractions for most people have been clearly shown to improve survival by eliminating largely arrhythmic deaths. In certain patients with dyssynchrony or a wide QRS complex on an EKG, biventricular pacemaker, or CRT, cardio resynchronization therapy has also been shown to reduce mortality and improve quality of life actually improve ejection fraction in the majority of patients. These intermediate device therapies implanted by electrophysiologists are also very important next steps.

Beyond that, as you said, surgical interventions may be an option. When you say valve interventions, that's an intervention that may occur very early on. If the primary cause of heart failure is aortic stenosis or mitral regurgitation or mitral stenosis, those interventions aimed that fixing those mechanical problems are a part of the very early intervention strategies. There's no point in letting a patient go on with medical therapy that has a critically blocked up valve. That may occur very early on. One other thing to bring in early would be bypass surgery. If patients' heart failure is because of multiple coronary blockages, bypass surgery or multiple stents might be an option early on as well. Once you've done all those things and the patient continues to be symptomatic, deteriorate, the heart function is now getting weaker, then you start talking about advanced heart failure therapy such as left ventricular assist devices for the appropriate patients and heart transplantation. Those are the advanced therapies that may be appropriate for a large group of patients. In particular, I would say as technology improves, ventricular assist devices are becoming viable options as a way of life for a lot more patients than they did five years ago. The technology is becoming smaller and smaller, they're becoming easier to use, easier to implant, easier to follow, so that is something to keep a close eye on.  

I think the future of heart transplantation has always been thought of as the gold standard. It’s the definitive therapy for advanced heart failure. We've always been limited by the supply of donor organ, although the last couple of years has seen an increase in the availability of donor organs largely due to the unfortunate epidemic of opiate overdoses, but the definitive treatment for advanced heart failure still remains transplants, although I can see a day when because of supply issues, left ventricular assist devices will become increasingly more important.

Melanie: Absolutely fascinating and you got to my question even before I was going to ask about looking forward to the next 10 years in the field. What else do you see and are there some treatments or research that you're doing at the Christ Hospital Health Network that other physicians may not be aware of?

Dr. Chung: There's actually a very exciting push to treat patients with normal ejection fraction. As I mentioned early on, we can broadly distinguish patients with heart failure as those with low heart function or low ejection fraction. In home, we talk about assist devices and defibrillators. The majority of treatments have been aimed at that population, but the growing group of patients with a normal ejection fraction, let's say 70%, who still have the same symptoms – shortness of breath, fluid retention – are very much in play. There have been very few treatments that have been studied and shown to be successful in that population of patients, in fact, none. The real cornerstone of treatment for those patients are at this point high blood pressure control, very careful fluid and salt management and that’s about it. Sleep apnea might play a role as well.

What we have actually started doing, and we just implanted the first one, is a little shunt device that we implant in the septal wall between the left and right atria made by a company called Corvia implanted percutaneously through the femoral vein, so the idea is that there is a shunt in place between the left and right atrium. The theory behind that is the fact that in most patients with heart failure and normal ejection fraction, the left atrial pressure or the pressure that causes shortness of breath is fairly normal at rest. The problem is when they start walking or exerting themselves, that pressure goes up very high, much out of proportion and compared to most people. That steep rise leads to disproportionate shortness of breath in these patients. The idea of putting in a shunt between the left and the right atria is that as that pressure goes up in these patients as they get up and walk around, that pressure now as a pop-off valve – it shunts blood into a lower pressure system on the right side – and therefore the left atrial pressure does not go up as steeply and therefore the patient may be able to do more before they become symptomatic. I think this is very elegant because it’s such a simple intervention that takes advantage of the natural history of left atrial pressure in these patients and it doesn't require power. It’s easily put in by experts who know how to do transseptal punctures and we actually did the first one yesterday. I'm very excited to see how she does and we have a number of patients who have been studied and lined up and waiting for this.

This promises to be a device that can actually treat a very difficult to treat refractory patients. These are also patients in whom remote continuous monitoring with things like cardiomems or other types of patches or devices that track multiple parameters that could actually tell us how to treat these patients before they decompensate. As an aside, I would say one of the most exciting things that is evolving is this ability to monitor multiple physiologic parameters in real-time as patients go about their daily lives and a lot of this can be monitored remotely. For example, there are little implantable chips or devices or little patches that can go on the chest, they can send us activity level, how many hours a day are you active, what your heart rate is doing during the day, when you're exercising, when you're sleeping, how often you breath on a minute by minute basis, at what angle do you sleep, on one or four pillows, how much fluid are you retaining in your chest and lungs, your body temperature, whether your heart is in or out of rhythm. Imagine having all this available on your phone to be able to look at on any patient that you like and it’s available today. The onus is on us to set up an infrastructure where we can efficiently look at a large group of patients and to impact these patients individually.

Melanie: Absolutely fascinating. What a great segment. What an interesting topic. Thank you so much for being with us today. For more information on heart failure services at the Christ Hospital Health Network, please visit thechristhospital.com/services/heart/your-care-and-treatment/heart-failure. For more information on Dr. Chung and all of the Christ Hospital physicians, you can find that at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for tuning in.