The Underappreciated Burden of Heart Failure

Peter L. Salgo, MD: Preventing hospital readmissions through evidenced-based medicine is a large part of managing patients with heart failure. As a result, much of their care falls to community physicians. In this Peer Exchange^®, experts in cardiology and hospital pharmacy are going to review the latest evidence in heart failure treatment and discuss ways to improve outcomes through better discharge procedures and care transitions planning.

I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of surgical intensive care at New York-Presbyterian Hospital. Joining me for this discussion are Dr Sheryl Chow, associate professor at Western University of Health Sciences College of Pharmacy in Pomona, California, and vice chair of the American Heart Association Clinical Pharmacology Committee; Dr Akshay Desai, associate professor of medicine at Harvard Medical School, and director of heart failure management at Brigham and Women’s Hospital in Boston, Massachusetts; Dr Scott Solomon, Edward D. Frohlich Distinguished Chair and professor of medicine at Harvard Medical School, and director of noninvasive cardiology in Boston, Massachusetts; and Dr Orly Vardeny, associate professor of pharmacy and medicine at the University of Wisconsin and clinical pharmacy specialist at the William S. Middleton Memorial VA Hospital in Madison, Wisconsin.

I want to thank all of you for being here. We’ve got a lot to cover. This is good stuff. There’s a lot of new stuff to go over, but before we get into the new stuff, let’s set the table a little bit. How big of a problem is chronic congestive heart failure in this country?

Akshay Desai, MD: Peter, it’s a big problem. There are about 6 million adults living with heart failure in the United States, and there are about a half-million new incident cases every year. And about half of those diagnosed with heart failure die within 5 years of the diagnosis. And amongst patients hospitalized in the United States in the Medicare-age population, heart failure is the principal reason they come into the hospital.

Peter L. Salgo, MD: I want to focus, just for a moment, on that 5-years-to-death. I think the population, and maybe even some physicians, doesn’t get it. When you speak to a patient and you say, “You’ve got cancer,” even in something with a 20-year good survival, they melt. If you say, “You’ve got heart failure,” they go, “Oh good, give me a pill.” That’s way off. Why is there this disconnect?

Scott Solomon, MD: First of all, it’s not that everybody who has heart failure is going to die within 5 years. That’s the median. And some people with the most severe forms of heart failure, what we would call class IV heart failure, may actually have a very short overall survival of even a year, which is worse than most cancers. But many people can live with heart failure for longer than that—even 10 years or more—and with proper therapy. That’s obviously one of the things we’re going to talk about today. People can live well with heart failure.

Peter L. Salgo, MD: Some people will live longer, some people won’t. That’s a short amount of time. And when you compare it to the same statistical analysis for other diseases, it’s shorter than many. Why doesn’t the American public key on heart failure the way they key on other diseases?

Sheryl Chow, PharmD, BCPS: When you combine the cancers together, you definitely have, perhaps, a higher rate of mortality. However, looking at just heart failure, comparing alone rectal cancer versus prostate cancer, heart failure still has the highest rate of mortality across the spectrum.

Peter L. Salgo, MD: I’m looking for the reason for the disconnect. People don’t get it, right? Heart failure. “That’s okay, I can fix that.”

Orly Vardeny, PharmD, MS: I agree. People don’t think of heart failure like they think of cancer. They think of cancer as something that will kill them relatively quickly, but they don’t think of heart failure in the same way.

Peter L. Salgo, MD: Is it our fault for not pointing out the risks here? Is it our fault for not pointing out that you really need to pay attention to this?

Scott Solomon, MD: I think it’s not so much that it’s our fault, but it’s that the public has not adopted heart failure in the way that we fear cancer. We have marches for cancer. We raise money for cancer much more so than we do for heart disease, in general. But that’s certainly true of heart failure. I think part of it is that we haven’t educated the public.

Peter L. Salgo, MD: That’s what I was trying to get at.

Scott Solomon, MD: What is heart failure? What does it mean? Most people, I think, don’t even understand what it means to have heart failure and to live with heart failure.

Peter L. Salgo, MD: I think you hear people say, “Well, Grandma had heart failure and she was short of breath all the time and her ankles swelled up.” And that’s as far as it goes, right? We’ve only got one ticker, and if that ticker is sick, that can be really dangerous.

Akshay Desai, MD: I think that’s exactly the problem. It’s that the public vision of heart failure is generally this syndrome of patients near the very end of their lives who are swollen and can’t breathe. And I think that heart failure is a spectrum. In fact, a lot of what we’ll talk about today is really that early spectrum of symptoms and cardiac problems, which are not patients you would classically think of as having heart failure at all. They’re patients with cardiomyopathies of various types. We know that half of the patients with heart failure don’t even have structural problems with cardiac contraction. Their ejection fraction (EF) is actually normal, and those patients, from the symptom standpoint, look a lot like the low EF patients. But classically, they don’t have some of the features that many clinicians think of as describing heart failure.

Peter L. Salgo, MD: We are talking about hospital discharge and preventing readmission. If you’re going to talk about discharge and potential readmission, they have to be in the hospital. What brings these heart failure patients with reduced EF into the hospital in the first place, Sheryl?

Sheryl Chow, PharmD, BCPS: Generally speaking, heart failure, in itself, is a progression. There is going to be worsening over time. But, of course, patients become nonadherent to medications. We all see that happening. They forget to take their medications. Two days later, they end up having increased shortness of breath and a change in their symptoms from their baseline. It’s those changes in symptoms that’s going to be a red flag for the patient to actually seek medical help. Also, diet of course. We all know that there will be a spike after the holidays, often times, because patients won’t eat properly and follow their own diet, as well as in times of stress. In our hospital, there was actually a peak in admissions during Valentine’s Day. So, an increase in stress and a catecholamine surge will lead to that.

Akshay Desai, MD: A few other things maybe to add. So, anything that worsens the underlying cardiac problem: if you have a new valve problem that develops or you have a new arrhythmia. Atrial fibrillation is a common precipitant. Patients who have heart attacks might have worsening heart failure at that time. And then there are lifestyle factors that are critically important, but progression of comorbidities, uncontrolled hypertension, wildly out-of-control diabetes, or worsening kidney function are all things that might precipitate hospitalization.

Peter L. Salgo, MD: And the new onset of atrial fibrillation is often a sequela of distinction of the atrial wall.

Scott Solomon, MD: And it’s a vicious cycle, yes?

Peter L. Salgo, MD: That’s difficult to control unless you control the heart failure first, right? Shrink it back down if you can control it at all?

Scott Solomon, MD: You do them both.

Transcript edited for clarity.