Heart Failure as a Systemic Disease

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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: I remember when I was in medical school that the drug we had was digoxin. “Give them digoxin; they’re going to feel better. They’ll pee some of this fluid out, and the heart will shrink.” Then, we were cautioned. “Oh, by the way, nobody lives any longer. We’re just going to give them [the patients] digoxin so they feel better. If you give too much, it’s bad.”

I remember that part. Then, I can recall when we started afterload reduction. I was horrified. We take people with marginal blood pressures and heart failure, and then give them something to reduce their blood pressure. But, again, it goes back to what you said: everything is changing. So, tell me about the cytokine storm you’re talking about.

Milton Packer, MD: It’s not a cytokine storm. What we’re talking about, here, is that physicians have to understand that when a patient develops heart failure (heart failure with a reduced ejection fraction), that what is happening is that there are hormonal signals, neurohormonal signals, that are bouncing off between various organs that are making the disease process inherently progressive.

They shouldn’t focus on the heart. They shouldn’t focus on the kidney. They shouldn’t focus on any particular organ. What they should focus on is the miscommunication that is taking place amongst the organs because the way we treat heart failure is [by blocking] that miscommunication.

Peter Salgo, MD: If what we’re talking about is miscommunication, and it’s not just about the heart, is “heart failure” even the precise term we want to use? If it’s more complex than that, why call it heart failure?

Michael Felker, MD, MHS: I think the key message is [that] the heart is fundamental to it, but it’s a systemic disease.

Scott Solomon, MD: It’s useful to think of it this way because all of the therapies or, for the most part, most of the therapies that we have to treat heart failure, block these abnormal signals—the communication that Milton [Milton Packer, MD] has been talking about.

Peter Salgo, MD: Okay. So it’s not just about improving inotropicity.

Scott Solomon, MD: It’s not at all about that.

Peter Salgo, MD: It never was.

Scott Solomon, MD: It never was. It’s never been a safe way to do that.

Peter Salgo, MD: No, not yet. Then, what are the goals of therapy? If you’re not working at the heart, per se, but you’re working systemically, what are your goals? What do you want for success?

Michael Felker, MD, MHS: There’s 2 things people talk about. They want to make patients feel better, and they want patients to live longer. As we’ve been talking about, a key focus for patients [when] treating heart failure is: what can I do to, what I’ll call, alter the natural history of the disease, in a way that’s going to improve morbidity and mortality? We think about that in heart failure, usually, as hospitalizations and death down the road. So, that’s the main goal of therapy, and I think that’s the message you’ve been hearing.

Patients, of course, want to feel better, and we want our patients to feel better. We have tools to help patients feel better. So, I think that’s a goal of therapy. But the danger is to be focused on that to the exclusion of doing the things that are required to alter the natural history. You don’t want to just say, “Well, I’ve given my patients some Lasix and now they feel better. Now I’m done.” That (altering the natural history) is an important goal.

Peter Salgo, MD: That takes 7 minutes, by the way, so that fits into the current reimbursement schedule.

Michael Felker, MD, MHS: Yeah.

Peter Salgo, MD: “Here’s your Lasix. Oh, 6-and-a-half minutes—we’ve got 30 seconds. Tell me about your symptoms.”

Michael Felker, MD, MHS: That’s when you spend that time putting it in Epic.

Peter Salgo, MD: Yes. Can we not go there? But can we? Let’s not focus on Epic [because] there’s so many others we could name. That being said, the goals of therapy, then, [are] interesting. You’re saying you don’t want them to just feel better, but you want to try to make them be better, physiologically.

Michael Felker, MD, MHS: This is like lupus and rheumatoid arthritis. [In rheumatology,] they talk about some things you give for symptoms, like prednisone. Then, there are disease-modifying agents. I think that’s a useful paradigm for heart failure patients. So, trying to control the volume status with diuretics makes people feel better and improves symptoms. That’s important, but it doesn’t modify the natural history of the disease. We need to focus on both, but I think that’s the other side.

Scott Solomon, MD: Mike [Michael Felker, MD, MHS] is sort of leading us into this issue that we like to call evidence-based medicine. There’s almost nowhere in medicine where we have more evidence than in heart failure—certainly heart failure with reduced ejection fraction.

The therapies that we use now have been informed by clinical trials that have tested these therapies [very rigorously]. Where we are today, at least in chronic heart failure with reduced ejection fraction, is [the result of] trials that have tested new therapies against placebos and newer therapies against older therapies, as well. Most of these have been focused on blocking this neurohormonal activation that Milton [Milton Packer, MD] was talking about earlier.

Peter Salgo, MD: Reading the cardiology literature, compared to the medical literature in general, I’ve rarely seen a group whose research is as crisp or as well focused and directed at those goals that you’ve mentioned. This is good stuff, and it’s where evidence-based medicine should be. The problem is, we don’t have enough elsewhere. But, you’re working toward the right end.

Milton Packer, MD: I think cardiology has been very fortunate, because we’ve developed a mindset and a discipline to ask and answer what we think are the right questions.

John R. Teerlink, MD: That has been facilitated by the severity of the disease and how bad this is for our patients.

Milton Packer, MD: But there are other severe diseases.

Peter Salgo, MD: You’ve also got a nice plumbing system to work with. On the other hand, you just made it more complicated by bringing the rest of the body into this.

Milton Packer, MD: But the thing that strikes, I think, all of us collectively, is that we know how to treat heart failure, but most of what we know works in heart failure is not being implemented in clinical practice.