What is heart failure, and what are the newest options for treatment and care for heart failure patients? Dr. Ron Falk interviews Dr. Patty Chang in this podcast about heart failure. Dr. Chang is an Associate Professor of Medicine in the Division of Cardiology at the University of North Carolina. She directs the Heart Failure and Transplantation Program as well as the Advanced Heart Failure and Transplant Cardiology Fellowship Program at 黑料网.
“..If we had donor hearts for everybody who needed a heart transplant, we could be doing transplants for 200,000 people a year in the United States. But the reality is, it鈥檚 about 2,000 lucky patients per year..who get a heart transplant.
-Dr. Patty Chang
Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair鈥檚 Corner.
Today we welcome Dr. Patty Chang who is an Associate Professor of Medicine in our Division of Cardiology. Dr. Chang has special expertise in heart failure and transplantation, and she directs the Heart Failure and Transplantation Program at 黑料网. She is also the Program Director for the Advanced Heart Failure and Transplant Cardiology Fellowship, which is designed to teach trainees all about heart failure.
Today, we are going to be discussing heart failure- latest research and treatment options, and some of Dr. Chang鈥檚 work in this field. Welcome, Dr. Chang.
Chang: Thank you, Dr. Falk.
Falk: Help me understand what it is like to have heart failure, if I鈥檓 a patient with it.
Chang: Heart failure is becoming increasingly common, and what we mostly see are patients with symptoms. Those who have symptoms are mostly a combination of shortness of breath, or fluid retention, or swelling. If they鈥檙e short of breath they鈥檙e usually not able to do what they used to do, so decreased exercise tolerance. If they have fluid retention like swelling, they often see it in their legs, or feel like their belly鈥檚 really bloated, or sometimes or often time their shortness of breath is caused by fluid in the lungs.
Falk: Fluid in the lungs, or swelling in other parts of the body, especially legs, can occur in liver disease, it can occur in kidney disease. How do you know it鈥檚 heart failure?
Chang: It鈥檚 a great question, because we don鈥檛 always know that it鈥檚 heart failure. Sometimes it takes a while to come up with the diagnosis, but the first thing one should think about is if their symptoms are not known to be anything else, or even if they have liver disease, it鈥檚 probably worth making sure that their heart鈥檚 in good shape. A very simple test, like an ultrasound of the heart 鈥� the echocardiogram 鈥� can give a clue about the heart function, and when the heart function is reduced, we call that reduced ejection fraction, or systolic dysfunction. That鈥檚 often a sign that the symptoms are from heart failure with reduced ejection fraction.
Falk: So what does ejection fraction mean?
Chang: The heart is a muscle that pumps blood to the rest of the body, and how much comes from the heart to the rest of the body is calculated as an ejection fraction. How much the heart ejects forward to the rest of the body. A normal ejection fraction is over 50 or 55 percent, so anything less than 55 percent is considered low, or reduced, and there鈥檚 different severities among that.
Falk: If I were a trained athlete鈥攚hich I鈥檓 clearly not鈥攚hat would my ejection fraction be? If I were ready to go to the Olympics or have just come from it.
Chang: That鈥檚 a great question because there鈥檚 a variety for athletic hearts too. But I think most athletes are at least above 50 percent, but some athletes are 70 percent. Some are 50 percent, but they should not be low, lower than 50 percent.
Falk: If my ejection fraction is lower than 50 percent, and I have shortness of breath, and swelling in my ankles, I may have congestive heart failure.
Chang: Right. One should make sure you鈥檙e checked out for that.
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Falk: What causes congestive heart failure? Why would I get it?
Chang: There are so many different causes. It鈥檚 not due to just one disease, but we often describe it as a syndrome that results from any disease that impairs the function of the heart. That鈥檚 mostly a function of its ability to eject鈥攃ontract or squeeze, as we often say. When it doesn鈥檛 squeeze well, or contract well, that ejection fraction is low. There鈥檚 also a type of heart failure where the ejection fraction is normal or preserved, and that鈥檚 called heart failure with preserved ejection fraction 鈥� previously known as diastolic heart failure. Often, what鈥檚 related to that is that the heart is so stiff, it doesn鈥檛 relax well enough for the blood to go forward, so the blood goes backwards.
The etiologies (causes) for either of those are quite vast. The number one cause in the US is coronary heart disease, or coronary artery disease, often from heart attacks or blockages in those coronary arteries. The second most common cause in the US is probably high blood pressure. So treating high blood pressure adequately through the years is very important to prevent this heart failure syndrome.
Falk: How about treating cholesterols?
Chang: Cholesterol contributes to coronary disease for sure; whether it contributes to heart failure is less clear.
Falk: And presumably I鈥檝e already stopped smoking or never smoked in the first place, because that would contribute to coronary artery disease as well.
Chang: That鈥檚 right. People who are at higher risk for heart failure are those who鈥檝e had smoking, higher cholesterol, who have also had lower educational status or socioeconomic status, mostly because it鈥檚 all related to coronary risk factors. But in addition, valvular heart disease, murmurs that go out of control or aren鈥檛 fixed in a timely manner, if they become severe valve disease, they can lead to heart failure also.
Treatment and lifestyle changes
Falk: When you see these people for the first time, and you know their ejection fraction is abnormal or there鈥檚 something else wrong with their ability to have forward blood flow鈥攚hat鈥檚 the first thing you鈥檙e going to suggest?
Chang: Most likely, they have these symptoms because they are full of fluid in their lungs or have fluid in their lungs. Often times, relieving that fluid by getting rid of it with diuretic medicine will do the trick.
Falk: Something like furosemide, bumetanide, one of those.
Chang: Right. The most common diuretics are called loop diuretics like furosemide, bumetanide, torasemide, or Lasix, Bumex, Demadex for the trade names.
Falk: Also some lifestyle modification to start with. Makes no sense to go eat a whole bag of salty potato chips when you鈥檙e using a diuretic to try to get out salt and water.
Chang: That鈥檚 right. In fact, the number one advice that we could give to really impact patient wellness is their own ability to control their symptoms by diet and exercise. We don鈥檛 want them to be sedentary and become couch potatoes, but at the same time, we want them to be very cognizant of their sodium or salt intake, and their water or fluid intake. Because we live in North Carolina鈥攍ots of people love sweet tea and BBQ, and that combination gets to be very difficult for the heart failure patients because they really can鈥檛 drink all that much and they cannot really eat that much salt.
Falk: After you鈥檝e done lifestyle modification and put them on a diuretic, anything else one can do?
Chang: Absolutely. Our field in medicine in general has evolved so well to note that certain medicines are so helpful to either stop the progression of heart failure, or maybe improve the heart function over time. These medicines are various classes which block various hormones in the body. They include beta-blockers, ACE inhibitors, also known as angiotensin converting enzyme inhibitors, a cousin of that known as angiotensin receptor blockers or ARBs. Another class is aldosterone blockers.
And we have a brand new drug that has made the heart failure professional community very excited, and that just came out last year, which was a combination drug of ARB with a neprilysin inhibitor. We call that ARNI for short because you know that cardiologists love abbreviations and acronyms! That is a new drug that seems to be the biggest thing since aldosterone blockers in heart failure and may be yet another tool in our kit to stop the heart failure from progressing and maybe improve survival.
Falk: What do you tell to patients who are on a number of medications? How do you have them remember what medicines to take when, and to avoid some of the side effects that may be bothering them?
Chang: Very difficult, and a good question, because it鈥檚 not just the doctor that is involved. It鈥檚 really a team of care providers, including the nurses that they interact with, pharmacists that work with us, and ultimately the family. We really want to encourage the patient and their social support to help them figure out how to take their medicines right. When we teach them about the medicines, it鈥檚 often about, 鈥淲ell this is for your heart in general,鈥� or 鈥�This is for your fluid management,鈥� and if we need to develop a schedule for you, or use pill boxes to remember. We try to educate them as much as possible about which medicines are for what, but in the end, it is a lot of medicines for patients to take, and it becomes a little difficult. That鈥檚 why sometimes getting their family member to help out helps as well.
Falk: So caregivers or family members in general are instrumental in making sure that these patients do well.
Chang: That鈥檚 right. Caregivers are the key to success. We鈥檝e had lots of people at 黑料网, faculty at 黑料网, investigating this topic, who I鈥檝e collaborated with to show that family members and caregivers can really provide important support to improve outcomes.
Research at 黑料网 in risk factors & in pregnancy
Falk: You鈥檝e done a lot of research in two general areas. One pertains to risk factors that are involved in developing congestive heart failure, and also in terms of how patients do long-term. Let鈥檚 start with the risk factor studies you鈥檝e been doing. Can you tell us a little bit about those?
Chang: Sure. My focus in that area has particularly been in the atherosclerosis risks in community study, of which 黑料网 is the coordinating center. This is a study that鈥檚 been following residents in four different communities for over thirty years, including a site in North Carolina鈥擣orsyth County. We have seen various associations over the years. These include, as we talked about before, hypertension, even if you prevent a little bit of a drop in the systolic blood pressure, that will not only reduce the risk of coronary artery disease, but reduce the risk of heart failure. Or the converse鈥攜ou increase the blood pressure more, the higher the risk for heart failure. We鈥檝e seen various other associations of, say, lung function or maybe even orthostatic hypotension, which has been curious. We certainly know that socioeconomic factors, especially low socioeconomic status is associated with worse risk for heart failure.
Falk: How about outcome? How do you tell somebody, 鈥淵ou鈥檙e going to do really well,鈥� or maybe you鈥檙e not going to do well? What are the determinants there?
Chang: We just recently looked at factors of medication adherence, and that certainly makes a big difference. As much as people can adhere to medications, and see their care providers in the medical setting, that will help them a lot.
Falk: You also have studied a very special population of patients who develop heart failure, and those are individuals who are pregnant. You get, in some patients, heart failure associated with pregnancy. How does that happen?
Chang: It鈥檚 a very difficult situation, and fortunately, relatively rare. That condition is called peripartum cardiomyopathy.
Falk: 鈥淧别谤颈鈥�鈥�鈥渁谤辞耻苍诲,鈥� pregnancy, in other words.
Chang: That鈥檚 right. Peripartum being around the time of pregnancy. We define that fairly strictly to say if they have no other cause for heart failure, it occurs in the last trimester of pregnancy, or up to five or six months after delivering. Again, it鈥檚 a diagnosis of exclusion with the hope that there wasn鈥檛 something else causing their heart failure. Often times, it can be reversible with good medical therapy, and in some cases it progresses very rapidly.
Falk: Does it result in early birth, or otherwise altering the course of the pregnancy?
Chang: Sometimes it does, if the mother is very symptomatic. Often times it doesn鈥檛 really affect the child so much, unless there鈥檚 an issue requiring the child to be born earlier, but that鈥檚 pretty uncommon.
Falk: What causes heart failure in an otherwise healthy, young person?
Chang: We don鈥檛 really know. I think it鈥檚 still to be determined, but there has been some research to suggest that maybe there is an abnormal form of a prolactin-related peptide in those who have this peripartum cardiomyopathy. It鈥檚 still under investigation on how much we need to pay attention to that potential pathophysiological mechanism, but what we have observed otherwise is various clinical risk factors such as, a woman who is classically more multiparous, or having had multiple pregnancies. Maybe having more than one child or having multiple gestations, they often might be older, and of African descent, and hypertension, either pre-existing or at the time of pregnancy.
Falk: You take care of a lot of patients who need a heart transplant or who have had a heart transplant. Who ends up needing a heart transplant, and how well do people do after they鈥檝e finally gotten one?
Chang: I think if we had donor hearts for everybody who needed a heart transplant, we could be doing transplants for 200,000 people a year in the United States. But what the reality is, it鈥檚 about 2,000 lucky patients per year in the United States who get a heart transplant, and who ends up needing it are those who really have progression of heart failure and are considered good candidates for heart transplantation, which often means, what makes them not a good candidate is things like being too old for a transplant, having too many comorbidities that prevent having the heart transplant. Also it鈥檚 very important that these patients have adequate social support, so that they can survive well and happily, after heart transplant.
For those lucky 2,000 per year in the United States who get it, generally they do very well and resume a normal life. I can proudly say that several of my favorite patients have become great spokespeople for heart transplantation in general by demonstrating what they can do after transplant. One has run several 5K races, climbed mountains in Canada, and was really a true role model for others having lost a hundred pounds after heart transplant. And he sends us pictures every now and then to thank us, to thank really the greater communities for his great gift of life. We鈥檝e also had a terrific spokesperson who was a nurse herself who ultimately had a heart transplant. She鈥檚 been a terrific spokeswoman for women with heart disease, and therefore women who need heart transplant.
Falk: Some patients aren鈥檛 lucky enough to get a heart transplant, and so they have an artificial heart. What鈥檚 an artificial heart, and how well do those work?
Chang: Technology is really great. These artificial hearts are now called Ventricular Assist device, or Left Ventricular System Device, to really support the left ventricle, or the left side of the pumping chamber of the heart. These LVADs really can sustain patients for years. They are a sort of heart pump or heart bypass machine to allow the body to function relatively normally for as long as that machine works.
Falk: How functional are those people?
Chang: These people are almost normal, except that they have some limitations, because it鈥檚 a heart pump that requires electricity, they will have a driveline that comes out of the body to connect them to a power source. So they can鈥檛 go swimming, they can鈥檛 take a bath, but they can certainly shower, and walk along the beach, and be careful with everything they do to make sure their driveline is nice and safe. But ultimately they鈥檙e doing everything they want to do outside of the water as long as they鈥檙e keeping their pump and driveline relatively safe. That includes running, that includes dancing, that includes doing whatever type of races they want to do too.
Falk: A heart transplant though is a better long-term possibility for those who get a transplant and are medically capable of getting one. Is that right, or is the technology so advanced that they鈥檙e almost equal.
Chang: Well, we all have biases, and I will share with you that my bias is that still, tissue is better than a machine. Ultimately the machines are going to catch up. At this point, many of us still think that the heart transplant is better because it鈥檚 durable. But you trade one set of problems for another and after heart transplant, there may be potential complications that the patient has to be vigilant about to prevent future complications or other problems related to transplant. But the machine, very simple. It鈥檚 a machine, you don鈥檛 have to take 20 pills in the first month after implantation, but the machine doesn鈥檛 last forever. Eventually, we think these machines will last very, very long. We鈥檝e heard of some of these LVADs supporting patients for ten years or more, and when the driveline gets internalized, and it鈥檚 all inside the body like a pacemaker or a defibrillator, maybe that鈥檚 when they can really last just as long as a heart transplant.
Specific advice for caregivers
Falk: Other than being present, other than being in the house, what specific advice would you give a caregiver?
Chang: I think caregivers can be really a representative for the patient, to not only care for them and make sure they鈥檙e doing well, but report for them, follow their symptoms, track their symptoms, help communicate with their medical care providers as needed. Bring them to appointments, support them during these difficult times when the heart failure gets symptomatically worse, or their prognosis becomes worse, or they鈥檙e experiencing more complications from their heart failure.
Falk: How do you convince a caregiver to speak up at a doctor鈥檚 appointment?
Chang: That鈥檚 a great question, because I think this is the art of medicine. You get both scenarios: sometimes the caregiver doesn鈥檛 say anything, and other scenarios where the caregiver does all the talking. There鈥檚 probably a happy medium between the two. Ideally with the patient talking the most. I think it鈥檚 very important to recognize the caregiver in the room and say to the patient, 鈥淢ay I ask your family member or support person here other questions? Or to chime in if they have any other thoughts?鈥�
Falk: I typically want to talk to especially the spouse because usually a spouse will tell you far more about what鈥檚 going on than patients do.
Chang: That鈥檚 right, and especially patients who tend to minimize their symptoms, and that鈥檚 where we get into the most trouble, when the patients don鈥檛 want to share how terribly they鈥檙e doing, but the spouse or caregiver says, 鈥淥h, well that鈥檚 not how it goes in our house.鈥�
Falk: Right. The truth eventually comes out. It鈥檚 always better for the patient and the caregiver.
Falk: Where would a caregiver, where would a patient get up to date useful information? Are there organizations that you would point patients to?
Chang: Yes, absolutely. We鈥檙e very lucky that there are a lot of professional organizations that support heart issues and cardiology in general, and then particularly heart failure patients. For example, there鈥檚 the American Heart Association, which is probably the largest professional organization for heart issues. The AHA has a very specific web site that is directed to caregivers to provide them with a support forum, and to give them some useful tips about how to become a caregiver. There鈥檚 also a similar society called the American College of Cardiology that would have similar resources. A specific professional organization would be the Heart Failure Society of America, and they really provide great resources, not just for professionals like the physicians, nurses, and other caregivers in the medical setting, but particularly for the patient and their caregivers for specific lifestyle instructions and advice, some explanations about the medications that they take鈥攔eally terrific resources there and I encourage people to look there.
Finally I think there has been a lot of interest among patients themselves to support each other. We certainly know of smaller societies that are patient-focused, that are disease-specific鈥攖here鈥檚 one called the Myocarditis Foundation. Then those who have LVADs鈥攖hey have their own web site, an organization called MyLVAD.com. There are support groups that are very active on FaceBook and other social media to help support each other.
* Update – Dr. Chang recorded a special episode focused on heart transplant, which was posted December 2017.
Visit these sites for information referenced in the podcast conversation.
- & the ACC’s