Goals of Therapy in 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

John R. Teerlink, MD: So, what we often see in these patients is [that] as they begin to decompensate, they kind of get put into 2 groups of forms of decompensation. There’s the congestive decompensation, and then [there are] the patients who have advanced disease [that] will have had these low output type of symptoms.

Peter Salgo, MD: So, they go from the silo of preserved output and transition to the low output?

John R. Teerlink, MD: Well, many of these patients can have preserved cardiac outputs if you measure them and still have signs of reduced peripheral perfusion independent of that. So, I don’t necessarily use the hemodynamics to guide that decision. But, once again, we do this crazy thing of talking to the patient and asking them how they’re feeling.

Peter Salgo, MD: See if they can complete a full sentence?

John R. Teerlink, MD: One of the things that’s interesting is [that] patients will present in multiple or different ways, but the same patient tends to present in the same way. I have patients who, when they get congested, do not get peripheral edema but they put the edema in their gut. They’ll have a little increased satiety. Their first symptom will be early satiety. They will feel a little anorectic—that’s actually [a sign or symptom of] their worsening heart failure. We’ll then say, “Okay, we need to work on reducing that congestion.”

Other patients will feel, suddenly, a bit more fatigued, a little [less] able to do some of the stuff [they normally could], and can’t explain that it’s necessarily due to shortness of breath.

And then there are the more classic patients who put on the peripheral edema and have pulmonary congestion and the rales and dyspnea on exertion.

Peter Salgo, MD: So rule one is to know your patient.

John R. Teerlink, MD: That helps.

Michael Felker, MD, MHS: But, I think the key point is that we don’t just want to control symptoms. One of the things that we have happen is patients come in and they say, “I’m actually doing pretty well, I feel about the same.” I see this in patients that are referred all the time. If you look at the chronic medications they’ve been started on, either they’re not the right medications, or, more often, they’re the right medications but [are prescribed] at very low doses.

And I think we can overuse the analogy to cancer, but this is where I think it is useful. So, in cancer, if you’ve got somebody on a therapy, you’re following something about their disease—whether you’re measuring their tumor or whatever. You’re saying that they’re responding or they’re not responding. We’re not just saying, “How do you feel today?”

This is something we’ve really been lacking in the heart failure space. How can we measure besides the symptoms? Are we actually modifying the natural history successfully, or are we not?

Peter Salgo, MD: Well, that’s what I’m trying to drill into.

Scott Solomon, MD: Mike [Michael Felker, MD, MHS] is making a really important point. Some people, I think, incorrectly believe that there’s such a thing as a stable heart failure patient. That’s probably a misnomer, because anybody with heart failure is in a fairly unstable situation medically. Their risk is extremely high, even if they haven’t been hospitalized recently and even if they feel reasonably well. If they have this syndrome we call heart failure, they’re at substantially increased risk of being hospitalized, of dying, and even dying suddenly before they have the opportunity to come in and say, “I don’t feel well, you need to do something about it.” That’s really a key point.

Milton Packer, MD: I want to underscore what Mike [Michael Felker, MD, MHS] and Scott [Scott Solomon, MD] said—there is no such thing as a patient with heart failure who is doing well.

Peter Salgo, MD: They’re doing “less bad” or they’re doing “worse,” but not “well.”

Milton Packer, MD: No. Think about it with the analogy of cancer as parallel, or not, as it may be. If you had someone with a diagnosis of cancer, and even if you surgically removed the cancer, you would remain incredibly worried [about] whether the cancer would recur. If there were signs that the cancer had spread, you wouldn’t give them one anti-cancer therapy and then see what happens, and then give them a second therapy, and then a third. What oncologists do is they give them 3 therapies all at once, because they want to kill the cancer and prevent disease from getting worse. That’s exactly the way we should be thinking about heart failure.

John R. Teerlink, MD: And the good news is that in heart failure we actually have those agents.

Peter Salgo, MD: And we’re going to get to a lot of them as we go along [with this discussion].

John R. Teerlink, MD: So we actually can do this.

Peter Salgo, MD: That’s the rationale, I guess, for early aggressive therapy—you don’t piddle around with it.

Milton Packer, MD: If a patient has heart failure, that is the cardiologic equivalent of saying that a patient has cancer that has spread. And, you would like to make the patient feel better, but that’s not the primary goal. The primary goal is to make sure that you treat the patient to prevent the recurrence and progression of cancer so you save the patient’s life. That is the primary goal. This means you need to start being aggressive as soon as you make the diagnosis.

Peter Salgo, MD: One of my oncology surgical friends used a phrase with a patient that resonated with me in terms of this discussion. The patient came in with a newly-diagnosed pancreatic carcinoma and that surgeon said, “As of now, your life is upside down. Everything has changed. You’ve got this diagnosis. We’re going for it.” I’m hearing the same thing from you.

Milton Packer, MD: Yes.

Michael Felker, MD, MHS: I think the difference is patient perception. I’m married to an oncologist, so I have a more intimate relationship with oncology than you all. I think when patients hear, “You have cancer,” [they] don’t need to be told that [it is a life-changing diagnosis]. They know that. Their friends are Facebooking them, and everybody’s wearing pink, and whatever. There’s this sort of mustering of resources that doesn’t really happen when somebody finds out they’ve got heart failure.

Peter Salgo, MD: Well, heart failure [to patients] is almost, “Gee, I know 20 people with it. All of my friends have it. All of my grandparents have it. What’s the big deal?” That’s what Milton [Milton Packer, MD], I think, is alluding to. It’s a change of perception of the severity and the risk of the disease.

Milton Packer, MD: As Mike [Michael Felker, MD, MHS] said, it has to be underscored enormously. If someone tells a patient they have heart failure, they have changed their life. That’s it. Forever. They have changed the way that they’re going to look at their life. They’re going to change the way they’re going to think about their life. They’re going to change the way they worry, because now, for the first time, they’ve been told they have a fatal disease. If they remember they have a fatal disease, and they also remember that, like in many forms of cancer, we can do something about it, then it changes the whole physician-patient relationship.