Characterizing Heart Failure

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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:

• Michael Felker, MD, MHS, professor of medicine and chief of the Heart Failure Section at Duke University School of Medicine, in Durham, NC
• Milton Packer, MD, Distinguished Scholar in Cardiovascular Science, Baylor Heart and Vascular Hospital, Baylor University Medical Center, in Dallas, TX
• Scott Solomon, MD, Senior Physician and director of Non-Invasive Cardiology at Brigham and Women’s Hospital, and Edward D. Frohlich Distinguished Chair and professor of medicine at Harvard Medical School, in Boston, MA
• John R. Teerlink, MD, director of Heart Failure at San Francisco Veterans Affairs Medical Center and professor of medicine at UCSF in San Francisco, CA

Peter Salgo, MD: Hello, and thank you for joining us for this MD Magazine Peer Exchange entitled “Managing Heart Failure Today: Current Best Practices and Newer Treatment Options.”

Since 2015, the FDA [has] approved two medications for the treatment of heart failure, following a decade without any new options for these patients. Although updated 2016 clinical guidelines provide guidance on the role for these therapies, heart failure populations are very complex. [Throughout this program], our panel of experts will discuss how they make treatment decisions and share their own clinical experiences with [the use of] these newer agents.

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 today for this discussion are:

Dr. Michael Felker, professor of medicine and the chief of the Heart Failure Center at Duke University School of Medicine, in Durham, North Carolina;

Dr. Milton Packer, distinguished scholar in cardiovascular science at Baylor University Medical Center, in Dallas, Texas;

Dr. Scott Solomon, senior physician and director of noninvasive cardiology at the Brigham and Women’s Hospital, Edward D. Frohlich, [MD], distinguished chair, and professor of medicine at Harvard Medical School, in Boston, Massachusetts;

and Dr. John Teerlink, director of heart failure at Veterans Affairs Medical Center, as well as a professor of medicine at the University of California, in San Francisco.

All right, we’ve got a lot of work to do. Thank you all for joining us. Let’s start with the basics of heart failure. We throw this term out all the time. I try to get a definition from my residents on rounds. They’re singularly incapable of doing so, so I’m trusting you. Who’s going to define heart failure? Who wants to start? Scott?

Scott Solomon, MD: When we think about heart failure, we think about a problem in which the heart is unable to provide enough output to the body without increasing its pressure. So this is a term, or a concept, that is useful in all the different types of heart failure.

Peter Salgo, MD: So if I may interrupt you, because it’s really critical and I want to be very clear about this, it’s not necessarily [true] that in heart failure cardiac output is decreased, but the cost of maintaining a good cardiac output is higher—left ventricular pressures, left atrial pressures, pulmonary venous pressures—that’s heart failure?

Scott Solomon, MD: Yeah. I like to think of heart failure as sort of a two-by-two table when thinking about the different types—chronic heart failure and acute decompensated heart failure. Then, on the other axis, we have heart failure with a reduced ejection fraction, and heart failure with preserved ejection fraction. There’s overlap. So you can have acute decompensated heart failure with preserved ejection fraction or reduced ejection fraction.

Peter Salgo, MD: Okay, does everybody agree with this? Can we start with this as a base?

Milton Packer, MD: I agree, but I think the most important thing is to remember that it’s a syndrome. It’s a collection of signs and symptoms.

Peter Salgo, MD: We’re not talking about etiology, we’re talking about a syndrome.

Milton Packer, MD: The clinical presentation is a presentation of someone who comes in, generally speaking, with exertional dyspnea.

Peter Salgo, MD: Okay, which leads me to my question—how are you going to diagnose this? Exertional dyspnea is one way to diagnose it, or at least [that will] lead you toward the diagnosis?

Milton Packer, MD: Exertional dyspnea, fatigue, fluid retention, a combination, or permutations of all of them is related to an abnormality of the heart. You can get those symptoms from pulmonary disease and other disorders, but when that collection of symptoms and signs is related to a heart problem, that is what we define as heart failure.

Peter Salgo, MD: That’s really important because there are a lot of different diseases, as you suggest, that can present this way. However, not everything is cardiac. So what testing do you use to parse all of this out?

Michael Felker, MD, MHS: I think Milton [Dr. Milton Packer] really hit it on the head. It’s a clinical presentation, so fundamentally (sort of old school) history and physical exam.

Peter Salgo, MD: Wait, are you suggesting we take a history and touch patients and listen to patients?

Scott Solomon, MD: It’s all avant-garde. Now, we’re on the cutting edge.

Michael Felker, MD, MHS: I think a lot of the things that we’re looking for are old school, physical exam things—signs of elevated cardiac filling pressure, pressures like the jugular venous pressure, obviously listening for rales, and looking for pulmonary edema.

Peter Salgo, MD: You didn’t mention my favorite—S3 (third heart sound). Has that gone by the boards?

Michael Felker, MD, MHS: No, I think heart sound is still useful, if it’s present. Its problem is it’s frequently not present. Once you suspect heart failure, I think there are a variety of important tests that need to be done. A key [test] is an echocardiogram, because [determining] the presence and the specific type of structural heart disease is going to be fundamental to understanding what you’re dealing with.

Scott [Dr. Scott Solomon] mentioned heart failure with preserved or reduced ejection fraction. Now, at least in some guidelines, there’s this mildly reduced ejection fraction category. Defining the specific type of structural heart disease is key. Then, if the diagnosis is unclear, there are other things—blood tests like natriuretic peptide level [tests]—that might be helpful.

Scott Solomon, MD: True. But the point is, clearly, that it can be very difficult to distinguish problems that cause dyspnea. Edema from lung issues, heart issues, other reasons, and even kidney failure can cause these problems, irrespective.

Peter Salgo, MD: I still recall the old Frank Netter joint frames and the guy, or the woman [that he drew], with heart failure. It’s the puffer, it’s the edematous guy, the guy who needs five pillows to sleep. That’s still heart failure, right?

Milton Packer, MD: It is, but that’s not necessarily the initial presentations.

Peter Salgo, MD: How is it typically diagnosed? Who presents?

Milton Packer, MD: Typically, a patient will come in and say, “You know, when I do the things of my daily activities, I just can’t do them. I get short of breath. I feel tired all the time. I can’t walk across either the room or two blocks. My ankles are swelling up. I’m just not feeling right.”

Peter Salgo, MD: Is it fair to distinguish between right and left [sided] failure? “My ankles are swelling up.” That’s right-sided, right? But it’s often a consequence of left-sided failure?

John R. Teerlink, MD: Well, yes. You point out the importance of us actually trying to combine the symptoms into the underlying etiology and causal mechanism. But I think one of the things that’s always amazed me about heart failure patients is that, frequently, these patients will have symptoms for weeks to months that are unrecognized. They go to physicians multiple times, and they’re either diagnosed with chronic obstructive pulmonary disease (COPD) exacerbations, leg edema from being older, and venous stasis changes, and all these things.

Peter Salgo, MD: You’re kidding, right?

John R. Teerlink, MD: Unfortunately, not.

Michael Felker, MD, MHS: And even patients themselves, because a lot of times [they are] older patients, say, “Oh, I sort of ignored all this because I thought I was just getting old.”

Peter Salgo, MD: Right, I hear that a lot by the way.

Scott Solomon, MD: Mike [Dr. Michael Felker] mentioned echocardiograms before as a way to distinguish between heart failure with reduced [ejection fraction] and heart failure with preserved ejection fraction. When you get somebody who comes into the emergency department with some of these symptoms that we’ve been talking about and we do the echocardiogram, it can be enormously helpful if it’s low. Then, we typically say, “Okay, they have signs and symptoms of heart failure and their ejection fraction is reduced. We understand what’s going on.” It’s much more difficult [to make that diagnosis] if ejection fraction is in the normal range.