Heart Failure: Changing the Natural Course of the 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: Let’s talk about people who have heart failure. You’d rather they not get worse. You don’t want exacerbations in these patients. You’ve made the diagnosis. Tell me about some of the factors you consider when you want to talk about the initial treatment approach. Can you modify this approach? What do you want to do?

Milton Packer, MD: First of all, when you make the diagnosis of heart failure, you are actually making the diagnosis of a lethal disease that progresses over time. The concept [is similar to cancer]. How many physicians would make a diagnosis of cancer and tell someone to go home and relax and not worry about it? “Everything will be okay.”

Peter Salgo, MD: And “Call me if it gets worse.”

Milton Packer, MD: And “Tell me if it goes high.”

When we make a diagnosis of cancer, everyone is so worried about what will happen in the future, where it will spread, what can be done to prevent it from happening. That’s exactly the same approach we should be taking with every single patient with heart failure.

Peter Salgo, MD: Okay. So, someone comes to your office—maybe de novo, maybe being treated in the real world. They come in and they say, “Here’s what I’m doing.” Or [they say], “I haven’t done anything yet.”

What factors do you put into your computer (which is between your ears) to say, “Here’s what I’m going to do.” “Here’s how we’re going to start”?

Milton Packer, MD: Everybody has to be treated into what I would call “clinical remission”—if I used it (the term) [in] parallel with [how it is used in] cancer. [The goal is] to maintain clinical remission as long as possible. And in order to do that, you would look at it as if it were a cancer. You’d be as aggressive as possible. You don’t say to someone with cancer, “Oh, we will treat three-quarters of your cancer and leave one-quarter.”

What you do is you treat the patient, every single patient with cancer, as if that cancer is going to come back and that cancer is life threatening. That’s exactly what we have to do with people with heart failure.

Peter Salgo, MD: How do you get the patient on board? I mean the patient says, “Oh, doctor, look, it’s just heart failure. It’s just a little shortness of breath. I can live with this.” Isn’t that what you hear?

Milton Packer, MD: The great thing about it is, the name is scary, and it should be. About 10 years ago, heart failure experts kept on thinking, “Heart failure is such a scary name, maybe we ought to change it a little bit and make it a little bit more comfortable for patients.”

But now, I actually think the name is wonderful. What it tells people is that, “Unless I [the physician] do something, you’re going to die of this disease. We have to be unbelievably aggressive at treating it.”

Peter Salgo, MD: Okay. I’m a patient. I come in to see you in your office. I’ve got insurance. I come to see you and I say, “Look, I’ve been short of breath now for a few months. My exercise tolerance is down. My local doctor actually told me I have heart failure. What do you want to do? How can I make this better?” What do you tell me?

Michael Felker, MD, MHS: Yeah. So I think there’s a few things, just to back up a little bit. We sort of get focused on treating chronic heart failure. But the first thing I think [we need] to figure out is if the patient has a reversible cause of heart failure. There are some things we can do.

So, “Do you have severe aortic stenosis?” “Do you have severe anemia, or some other tachycardia, or some other thing?” But let’s assume, for the sake of argument, that we’ve ruled out all those sort of things and you’re left with heart failure. We mentioned echocardiogram before. A key thing that’s going to be a turning point in how we decide to treat you is “Do you have reduced ejection fraction or preserved ejection fraction?”

Peter Salgo, MD: So you’re going to put them into 2 silos—the reduced ejection fraction and the preserved ejection fraction.

Michael Felker, MD, MHS: The reason for that is [because of] the tools that we know work for the patients who have reduced [ejection fraction]. It’s a much larger menu of things we say we know are going to work and modify the natural history of your disease.

In the preserved ejection fraction group, we have much less certainty about what the right thing to do is. But I think, assuming for the sake of argument, “You’ve got reduced ejection fraction.” I think Milton [Milton Packer, MD] said it well—I think the key thing is to, in a relatively short period of time and as aggressively as possible, get you [the patient] on a cocktail of medications. It’s not just going to be one. [The medicines] are going to manage symptoms—that’s a short-term goal. [Additionally, in the] long-term, [the medicines will] alter the natural history [and induce], if you want to use the word “remission,” of your disease, to prevent progressive remodeling and the morbidity and mortality associated with it.

Peter Salgo, MD: This is interesting to me because what I’m hearing from you guys is not just, “We’re going to give you some pharmacology—your medicine, exercise, maybe some lifestyle [modifications]—to make you feel better, make your heart shrink a little bit, preserve your cardiac output, decrease your LA (left atrial) pressures, and get the water out of your lungs. But I’m hearing that you’re going to remodel the heart and make the heart better. No?

Milton Packer, MD: No.

Peter Salgo, MD: No? I’m hearing wrong? Did he misspeak?

Milton Packer, MD: No, he told you the truth.

Peter Salgo, MD: I heard it wrong.

Milton Packer, MD: No. What he said was, what needs to be done here is not to focus on the heart, but to focus on the patient.

Peter Salgo, MD: But I heard remodeling. That means the heart to me.

Milton Packer, MD: That may be true, but the goal in treatment of heart failure is to make the patient feel better and live longer.

Peter Salgo, MD: Fair enough.

Milton Packer, MD: If you can do that, and you understand how that might work by making the heart better, that’s great. But the goal is to make the patient live longer.

Peter Salgo, MD: Right, understood. But did I actually hear that, in the pursuit of that goal, we can actually make the heart healthier?

Milton Packer, MD: Yes.

Peter Salgo, MD: All right, I did hear you right.

Michael Felker, MD, MHS: You’re both right. In the drugs that we know are effective, [we think that the] effect is substantially manifest by seeing the heart remodel, either in a favorable fashion (that’s the best-case scenario), or at least stabilize and not have adverse, progressive adverse remodeling.