Managing Heart Failure Today: Current Best Practices and New - Episode 2
The MD Magazine Peer Exchange “Managing Heart Failure Today: Current Best Practices and New Treatment Options” features a panel of physician experts discussing key factors to consider when making treatment decisions for patients with heart failure and their own clinical experiences with recently approved medications for the treatment of heart failure.
This Peer Exchange is moderated by Peter Salgo, MD, 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.
The panelists are:
Peter Salgo, MD: And I think that it is worth [considering] if we are going to carve out, from this discussion, the valvular patients with valvular-induced heart failure, because that’s surgically correctable or not. But we’re talking about medically correctable, or medically diagnosable, heart failure.
Milton Packer, MD: Since most patients with heart failure present to a family physician, a generalist, or an internist, the most important message is that these are individuals who have a really serious illness.
Very often, what will happen is that the patients won’t know it’s a serious illness and they’ll wait for weeks or months. Then, when they see a physician, the physician will say, “Well, you know, we’ll give you a little bit of this and a little bit of that, and we won’t pursue diagnostic tests right away. We’ll just see how you do.”
The most important message I think that we can get out is that when a patient presents with a syndrome of heart failure, it’s like presenting with the diagnosis of cancer. It’s that serious.
Peter Salgo, MD: In fact, one of the things I was taught, and I think it’s still true, is that patients, all-comers, will say, “Well, I’d love to have heart failure. I’d rather have that than cancer.” Look at the morbidity and mortality of these diseases—it’s pretty scary. So, I want to nail down very quickly, at what stage is heart failure [typically] diagnosed? If they’re sitting at home puffing away and squishing away, when they come in to see you, what’s the typical patient [presentation]? Is it far advanced? Is it early?
Michael Felker, MD, MHS: I think the initial presentation can be varied. So [in] some people, their first presentation is showing up in the emergency room in bad shape. But more often, as Milton [Dr. Milton Packer] said, it usually comes on subacutely over a long period of time. Those are people who are frequently coming to their primary care doctor or family doctor.
There’s a variety of ways you can classify severity. There’s the New York Heart Association classification, which is really a measure of how symptomatic people are. I think a more useful one is the American College of Cardiology/American Heart Association (ACC/AHA) classification, which sort of divides people into your risk factors—stage A, structural heart disease but no symptoms, yet; stage B, the development of heart failure symptoms; stage C; and then advanced heart failure, stage D.
Peter Salgo, MD: Patients come to you with heart failure. They’ve had a couple of myocardial infarctions, or there’s something going on. What are the real nasty, or the common comorbidities, that these patients present with?
John R. Teerlink, MD: I think a lot of it depends on what your specific practice setting might be. If you’re in an advanced transplant center, the patients that you see as heart failure patients are very different than if you’re in general practice. But clearly, the same major causes of heart failure remain [as] hypertension and coronary artery disease.
Many years ago, hypertension led the way. Now that we have actually been effectively treating hypertension, coronary artery disease has supplanted [hypertension] as the number one cause. But these patients, in general, are elderly patients with a mean age around 70, 75. They come [in] not only with heart failure and either the hypertension or coronary artery disease, but [with] all the other substrates that come along with that—such as the diabetes, other issues in terms of their peripheral vascular disease and the atherosclerosis that extends throughout their entire vasculature.
Peter Salgo, MD: I know our viewers have heard all the literature [in regard to hypertension]. They’ve read the literature, they’ve heard the popular press, and their patients are reading the web. The recommendation for the control of hypertension has changed in that it’s gotten more aggressive over time. Is there some magic number that’s going to make people develop heart failure less?
Michael Felker, MD, MHS: I think hypertension, as John [Dr. John R. Teerlink] said, is one of the biggest risk factors for the development of heart failure. If you look at the various bad things that can be caused by having hypertension, stroke, or coronary disease, development of heart failure is really one of the primary ones.
As people know, there’s new data now suggesting that in the general population, lower blood pressure targets may be more effective. One of the main ways it’s more effective is [in] reducing incidence of heart failure. What I think that we know much less about [in patients with] heart failure, is what blood pressure should we be targeting? That’s a much trickier and bigger topic. But, I think the take-home message is “good control of chronic hypertension in the general population is a key heart failure prevention strategy.”
Peter Salgo, MD: I’ll just throw one grenade on the table. Hopefully we’ll spend 30 seconds on it. If you’ve got a very high left ventricular end-diastolic pressure (LVEDP)—so, increased left ventricular wall pressure—and you dump somebody’s diastolic pressure down, aren’t you decreasing transmural blood flow and increasing ischemia?
Milton Packer, MD: Well, we haven’t thought that in about 30 years. In general, the way we think about heart failure, now, is really more of a remodeling process. So, anything that makes internal pressure and internal volume higher has an adverse effect on structure and function, and anything that reverses that could have a favorable effect on structure and function. The reason why this is important is you’re not just treating the patient to make them feel better. You’re treating the patient to make them live longer.
Peter Salgo, MD: Fair enough.
Michael Felker, MD, MHS: Imagine if you gave somebody an intravenous vasodilator in a very acute setting, that would be operative. But usually we’re talking about starting oral agents and at a relatively modest dosing process.
Peter Salgo, MD: Gradual remodeling process.
Scott Solomon, MD: And load is what we’re lowering when we lower blood pressure.
Peter Salgo, MD: Got it. So you’re in afterload function.
Scott Solomon, MD: Think about the heart as a pump. It’s like going to the gym and doing Nautilus. If some guy comes along and puts up 300 pounds, you’re not going to be able to do it. You have to decrease the load. That’s what lowering blood pressure does.