Rationale for Early Aggressive 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

Milton Packer, MD: Any time you have a patient with heart failure, you have a deadly disease. It doesn’t matter whether the patient is stable [or] the patient’s getting worse. The patient has a deadly disease. That patient needs aggressive therapy to prevent that deadly disease.

Whether they happen to come in as an outpatient and report worsening symptoms, or not, is less important than understanding they have an underlying disease that’s going to kill them.

Peter Salgo, MD: Right. But that really wasn’t where I was going. I’m agreeing with you that this a bad disease. It’s a lethal disease. Patients need to know that they’re at high risk of dying of this disease unless we get really busy with this. All I’m saying is that when they come back to you with this diagnosis, and they have X or B, or Z or Y, that’s a little worse. It doesn’t matter what those symptoms are. Every one of them is worrisome. It’s a lethal disease—get busy [managing] it.

Milton Packer, MD: There is no such thing as a patient who comes back to a physician with heart failure and says, “You know, after you put me on the medications, I felt much better.” And the inappropriate thing is for the physician to say, “Well, I’m really happy about that.”

Peter Salgo, MD: And, “Have a good day.”

Milton Packer, MD: That is the biggest mistake we see in clinical practice.

Peter Salgo, MD: What should you say?

Milton Packer, MD: What you should say is, “I’m glad you’re feeling better. We’re going to try to keep you feeling better, but we have to save your heart. We have to make sure your heart doesn’t get worse. You have a disease that is going to kill you, and it doesn’t matter whether you come and tell me you’re feeling better or not.”

Peter Salgo, MD: Okay, so exacerbations are the wrong topic. Heart failure is the topic.

John R. Teerlink, MD: I will throw you a lifeline on this exacerbation. As it was discussed earlier, Scott [Scott Solomon, MD] brought out that 2 by 2 table, and acute decompensated heart failure was a component of that. And, certainly, there’s a lot of research that is going on right now, that all of us are involved in, in terms of trying to look for agents that might be able to intervene in the acute decompensated situation and might provide better short-term and intermediate-term outcomes.

So, I don’t think we want to ignore that as an opportunity to treat these patients more aggressively, at a time where there’s kind of this neurohormonal, hemodynamic, and cytokine storm, if you will. But, I think to Milton’s [Milton Packer, MD’s] point, we also need to be chronically addressing this as an emergent issue.

Milton Packer, MD: The way to really think about it is that if you have a patient with cancer and you get a chest x-ray, and they have metastatic disease to the lung, it really doesn’t matter to the oncologist whether the patient is complaining of shortness of breath from their metastatic disease or bone pain from their metastatic disease. What is of concern is that they have metastatic disease.

Peter Salgo, MD: Fair enough.

Milton Packer, MD: And it needs to be treated.

Peter Salgo, MD: So let’s move on just a little bit. I think the tendency is, and certainly when I speak to the medical students and the residents, this is all new. This is all heart failure. This is a disease that we’re just getting our arms around, but heart failure is an old, old problem. What is the history going back through time of heart failure and the treatments the doctors have ordered for it?

Milton Packer, MD: Heart failure is actually the oldest disease in human history which is not related to an infection or trauma. There were reports of heart failure going back about 5000 years. It used to be looked at purely as a disease of fluid retention. So, people would take fluid off in a variety of different ways and they would assume that the patient was better. Then people realized there actually is something wrong with the heart in people with heart failure. Believe it or not, the recognition that there was something wrong with the heart in patients with heart failure is only about 40 years old. Before that, that concept was not well appreciated.

Peter Salgo, MD: That’s actually shocking.

Milton Packer, MD: It is shocking.

Milton Packer, MD: Yes. Then we realized that heart failure really isn’t just a disease of a heart, it’s a disease of the circulation. The circulation consists of the heart, the kidneys, the brain, and the entire interplay of these organs. What actually happens in heart failure is that the interplay of these organs is what is causing signals to be sent amongst the organs to cause the disease to get worse. So, our therapy, now, is not targeted toward fluid. It is not targeted toward the heart [either]. It’s targeted toward blocking the signals that cause the disease to get worse.