Peter Eckman, MD, discusses and defines heart failure. He goes into detail about the medications and devices used for heart failure.
Welcome to cardiovascular conversations with Minneapolis Heart Institute. Your podcast for the best and cardiovascular content. Cardiovascular Conversations is a new, creative and engaging content source for the latest and greatest in cardiology topics and innovation. Way are your hosts, Fred, Um, use and I'm Jason Hicks. Enjoy the podcast. Today we have the pleasure of speaking with Dr Peter Eckman, cardiologists specializing in heart failure management at M H I. There's so much good info in this 30 minute podcasts and Italy be wanting for Mawr. Details on the latest trends in heart failure management Enjoy the podcast. My name is Peter Eckman. I am a cardiologists specializing in heart failure at the Minneapolis Heart Institute. Heart failure is one of those things that I think obviously, we see so much of it in all areas of medicine, especially frontline medicine, emergency medicine, which is what both friend and ideo. It can be a little bit nebulous, I think to for our listeners, for this podcast would be nice to just sort of define what is heart failure now. Well, I think the naming is important. The systolic heart failure or heart failure with reduced ejection fraction is usually defined as someone whose ejection fraction is low and depending on what studies you look at. Um, certainly less than 40%. And often, even if you're 45 or 50 many would say, Well, that's not normal. Um, And then the heart failure with preserved ejection fraction is typically when you're 50% or higher. The syndrome of heart failure is one that you can't tell by looking at someone which version they have, and it's usually characterized by, uh, fluid retention. Disney on exertion is incredibly common fatigue, Um, and often the signs of congestion. Um, and that's something that I think has also changed over the years is that the term heart failure and congestive heart failure are not necessarily synonymous. Another thing that often helps distinguishes whether it's from an ischemic ideology from heart attacks, corner disease, etcetera or non ischemic, which could be any number of you know, 50 different causes. I could also add right heart failure is often, uh, caused by left heart failure, but we also see it in the settings of pulmonary embolus, pulmonary hypertension. Some degree of right heart failure is very common in patients with chronic obstructive pulmonary disease, or sleep apnea. Um, and the right ventricle is a lot harder to characterize just because of the shape of it medications. I think we all know that typically, heart failure patients are on at least a few different medications. What, in your experience has changed as faras meds that air used for heart failure? How has it evolved? Even in the short course of your career? I will say that the heart failure with preserved ejection fraction remains challenging and that there aren't medications that air specific for that. But the heart fire with reduced ejection fraction. That's where we've had the most success in terms of developing medications Right now, this is, uh, condition that has four classes of medications that have a very strong evidence base. The first is beta blockers. The second is either angiotensin converting enzyme inhibitors, angiotensin receptor blockers or the new kid on the block. The ancient tension receptor? Nope. Ellison inhibitor. That's the Val certain secu betrayal. Um, and that's one that's the, you know, Newer has been out for about five years, um has pretty clearly and consistently shown benefits over the ace inhibitors that it was tested against, um and I would even say I'm in my practice. I've virtually stopped using ace inhibitors, um, in part because they have some that's not high, but incidents of cough, for example, and angiotensin receptor blockers are equivalent in terms of cost. They don't have that side effect, and it's easier to transition from that to the angiotensin receptor Nepalis An inhibitor. Secure patrol. Well, certain are you seeing, um, e I haven't I mean, it's been described, and it's, you know, certainly people in the emergency room should be aware of that as ah possibility. Um, the incidents of it is quite low. Um, and that was one of the things that they explicitly tested in the trials of these medications because of the theoretical concerns about it. Um and so the the third class is a mineral core dacoit receptor antagonist that spironolactone a player known, and then the fourth is and this is the one that's really new and really exciting is the SG lt two inhibitors and the DAPA HF trial that was published a year ago in September, I think is one of the most paradigm shifting heart failure trials I've seen in my career. And that it took a drug that was a diabetes drug that Now we're saying this is a heart failure drug that Oh, by the way, it also works for diabetes. And so that really was a huge change. Um, the access to these medications has been a problem. It wasn't until May that it was FDA approved for use in people who did not have diabetes. And so we got some pushback from payers, and we try and put people on this and say, Well, you don't have diabetes. Um and so that's changed. They still remain expensive. So these four drugs are really the cornerstone right now. You know there's no free lunch. Any of these medications can cause problems. When I'm adding these medications, I am routinely backing off on diuretics. The same is true for the secure patrol, Val certain, um And so I have a lot of patients now that by being on this contemporary four drug cocktail, don't need or Onley need very sporadic as needed diuretics. I have to be honest. I learned a few new acronyms here. Think I've seen them before, but I get that given that much thought as to what they actually mean but h f r E f and h f p e f. And those are heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. You may also C h f M R E f, which we argue. You know, we have to have something to talk about meetings and that one is heart failure with mid range ejection fraction. And part of it is many of the trials that looked at reduced the F specified 40% or less. Many of the trials for preserved DF said 50% or more, and so there's kind of this gray area where we don't always have great data to guide us. Do you wait for those patients to declare themselves and one group or the other? You typically kind of man? Is there actually specific therapies for those mid range heart failure patients? My bias has generally been to start them on the reduced DF meds. I mean, most of them are very well tolerated, and especially that you know, a say, RBI beta blockers, they're very affordable. I know you know. The majority of these patients we see who come in are anemic and a lot of time, I suppose. Iron deficient anemia There's others. What can you talk to us? Can you talk to us a little bit about treating especially iron deficiency anemia? Maybe just touch shortly on there briefly on that. There have been a number of studies looking at this. Where there has been some promise is for iron deficient patients to treat them with iron supplementation. Um, Orel Iron supplementation has not been very effective in heart failure patients, which is not entirely surprising. It's not even very effective in people who don't have heart failure. And if you add the bowel oedema, it's poorly absorbed. And so there are a couple of studies going on right now, looking at the role of intravenous iron supplementation. And in contrast to a lot of other things, I can tell you that is pretty easy to talk people into getting iron infusions because it's basically a mineral. But there is some data to suggest that it improves my cardio energetic. This blood volume analysis, um, how this kind of articulates fairly well with the anemia piece of it for heart failure patients. Are you able to speak to that? And then some of the drawbacks of that as well. We're assessing patients volume status all the time. One of the gold standards from and arguably the gold standard is there's a way Thio use a nuclear medicine techniques. There's a radio labeled albumin product that we have been using. We do the test here about 100 times a year, and you give a tiny dose of this radio labeled albumin. And by measuring how fast it leaves the bloodstream, you can get a very good quantitative estimate of someone's plasma volume. And what's the red cell volume? This is a test that we've been using predominantly in the inpatient setting, although it is available as an outpatient test in some centers to, um, as another way for us to measure, um, level of congestion. And another thing that it gives us is. Are they anemic? So is it essentially, when the patient otherwise feels okay, feels like at their baseline that you're doing this test? Are you doing it when they're really symptomatic? When when do you do it? I've been using it when I can't figure out their volume status, you know, maybe that I think they're congested, and I try and decongest them in their renal function gets worse. And so maybe I'm wrong. I tend to use it when I'm when it's not clear. You know, there are some centers that are using it more aggressively to sort of determine who is adequately decongestant for discharge. I think it may have a role in that type of a setting. Um, but that hasn't been how I've used it. Great info and discussion so far with Dr Eggman. Let's move on to gadgets and devices. The volume analysis. I think it's a nice Segway Thio devices, gadgets, etcetera. There's so much out there right now. Um, I wonder if you could just touch upon a number of these and maybe even give us examples of this is the kind of patient I would like. Teoh, you know, consider using this device for this implant, for sure. So although I mentioned earlier that not all heart failure patients have congestion, many do in congestion is probably the number one reason that is driving them to seek medical care can't breathe at night, short of breath. You know, that sort of thing is driven by congestion. Needless to say, if we can monitor for that. Catch it early, Treated early. We can keep people at home. They don't have to come to the emergency room. They don't have to be admitted to the hospital. We've tried a lot of things as, ah, medical community. We've tried scales. We've tried phone systems. Um, those have had pretty disappointing results. Um, but more recently we've had a couple of other technologies that have looked to try to manage this mawr proactively. And more objectively, one is with some of the pacemaker systems do thoracic impedance measurements. The idea here being you have more water in your lung, you've got lower impedance across that tissue, and that can change electrical parameters. One of the problems with that is that if you're not getting the measurements frequently enough, you don't have enough warning to be able to do something about it. And so the technology that's been probably best studied, or at least best documented in terms of the benefits is an implantable pulmonary artery sensor. Um, the one product that's currently available is called cardio memes. And so that's the term people may hear. This is implanted in a same day, outpatient procedure, much like having a pulmonary artery catheter put in. It's a small device. No battery or anything is left behind in the pulmonary artery. Patients then lie on a coil that takes the pressure reading, sends it to us over the Internet. And then we use that to help adjust their medications. Most often diuretics, um, that's been shown to decrease hospitalizations by half. Um, the people that it's indicated for our folks that have been hospitalized with heart failure and importantly, it's useful and has been proven useful in people, both with reduced and with preserved ejection fraction. Um, and so that's a technology that has really changed how we treat heart failure patients. Part of what I like about it is, um, it's giving us pressures. And if you look at well, what are the tools we have to modify people's disease? We have all these anti hypertensive medications. We have diuretics, which also have some effect on blood pressure. And so this is a It's giving us a therapeutic target that we more consistently know what to do with it. Then we do with a scale. Other things people are are looking at all sorts of wearable devices whether it's, um, heart rate variability monitors. Whether it's, um, you know, activity, you can get sense a sense of how well you sleep. Um, one of the things that I have found frustrating about some of these other technologies is, you know? Okay, well, let's say heart rate variability has an impact on your prognosis. And if you have low heart rate variability, maybe you have a worse prognosis. Well, if somebody calls me and says, Doc, my heart rate variability is down, I don't know what to do with that. I don't have a pill for that. Um and so some of these markers, What I think is important is that we're getting information that's clinically actionable on that we have something we can do about it, which is the reason we do it right. Otherwise, we're just It's cool, another cool device, and we're just generating mountains of data. And then somebody's got to type that in the M R or scan it in, and we got a bill for it, and it just creates a mess in terms of the downstream care that needs to be done from it. Do different classifications fall into this? Four implant mint? Or is it only those three and above kind of thing? Well, it typically, I mean, almost everybody is being admitted to. The hospital has had N Y h a Class three heart functional Class three heart failures. So I think those two tend to go hand in hand. And so it's anyone who's been admitted, some of the populations that I found it particularly helpful. Um, a couple of examples. People with mobility issues where it's hard for or impossible for them to get on a scale. Um, I have one woman who had a spinal cord injury after ah, uh, complex aortic surgery, where she had very poor use of her legs and, you know, wonderful patient, very adherent, diligent daughter. They just could not weigh her. And she got a cardio memes. And, you know, she hasn't been in the hospital in over two years, whereas before that was in all the time, it was just a mess. Managing her. Are there any of these devices that you find are just in terms of, ah, you know, time and attention laborious for the patient or onerous to even have they have we found that any of them are just ah lot tougher toe manage than others. I think the user experience is really critical on this. Um, but you have to balance it. You know, the implanted devices that do the thrust of competence monitoring. Well, that's zero work for the patients. But we is a medical community in partnership with a You know, companies that make these devices never had a pathway where, you know, how often are we interrogating this? Are we getting the information? Is it actionable? Um, not to mention if it's in an implantable device, it has a battery. Well, every time you interrogate that device, you burn up another. I don't know, 20 minutes of battery life. And you do that every day. You've appreciably shortened life expectancy of that device. Eso there's always trade offs. We go down the algorithm of like, um, cardiac re synchronization therapy or I C. D s. When are you talking to patients about implementing those type of modalities? I often talk to them pretty early on after their diagnosis, but it's a ZMA much a matter of, you know, here's the road map of heart failure management, and, you know we're going to start with. Let's get your fluid off. Let's make sure you're comfortable from that standpoint. Let's start these medications that reduce the risk of this recurring reduce the risk of progression. Hospitalization, death, etcetera. Um, often this will get better, especially if it's a non ischemic ideology. If it doesn't, then we'll talk some more about whether or not a defibrillator might make sense for you and the bi ventricular pacemaker. Um, you know, they're they're separate decisions and that there's some people for whom a bi ventricular pacemaker makes sense in a defibrillator does not or vice versa, although I would say much of the time. Both do the Bible. Particular pacing is driven largely by their Q. R s morphology. So the left bundle branch block patients are the ones that really are likely to benefit. Right bundle? Not as likely, Um, and there's still some work tryingto help us predict more accurately. Who's going to respond? And if people don't respond, what can we do to change the timing or the recent realization so that we're getting the benefit out of these devices so safe to say that if you're considering a bi ventricular pacemaker, it's likely that that patient is also going to require potentially require a defibrillator. So you do sort of a combination devices. Yeah, it's And in the device the can, so to speak of the generator. It's a little bigger if it does both, Um, and you know the Bible, particular pacemaker alone. You don't need a high voltage lead, so it's a little smaller lead that goes into the right ventricle. Um, but typically it is done as a single procedure. It's kind of a dual purpose device. I mean, I you know, the way I explain it to patients is the bi ventricular pacemaker is designed to sort of force your heart toe work together. The defibrillator is there. It's an insurance policy in case your heart goes haywire. And by the way, all defibrillators have a backup pacemaker function. In case. For some reason, your heart goes too slow. So and people often don't know that, you know they'll come and they say, Well, I have a defibrillator say, Well, you're almost never using your pacemaker and they get confused. They said, I have a defibrillator, so well, it kind of does both, and this is kind of a naive comment, and I don't think I've ever really looked at it very closely. But when these people have a bi ventricular pacer place for left bundle branch block or a widened QRS, are we actually able to discern that on the E. K G? Will it show that the Q R s shortens, or is that no, that's a great question, and in fact, there's some work. One of my partners, Doctor Bank Over in ST Paul, has spent a lot of time working on. How can we, with surface EKGs understand when it's something is electrically optimal? Because getting that timing right has been a challenge. And there's been a lot of work with echo and other parameters to try to understand. Do you pace the Elvia little First? There are via little first, how much of a delay do you need. And so if you are having very good effective by ventricular pacing, you often will see sort of mawr characteristic curious wave forms on an E K. G. So it's it's actually a very good question, but it's not a simple thing to just say, You know, I can't usually look at an E K g and say, Oh, you're by the Pacers. Perfect. Yeah. Um, you know, the the other kind of interesting devices that are out there are the ones that actually alter the anatomy A bit of the heart. Can you comment on those a little bit? E think the an atomic device that's had the most attention in the heart failure space over the last couple of years is the mitral clip trans catheter edge to edge repairs. It's often called Andi. I'll be I'll be honest with you. I was surprised that the co opt trial was as positive as it waas. I My experience with these patients was that it would take someone with sort of six plus m are down to four plus, and they still had a lot of my truck agitation and a lot of symptoms. Um, but I have to give the, you know, the study investigators a lot of credit that they really were able to show some significant differences. Very good safety profile. Now, what's important about this device is that it's really appropriate Onley after you've had your medications optimized, um, and so that's ah, critical first step in a lot of the patients that when our center was participating in this trial in one of my partners, was the main medical investigator. He found that almost half the patients that were referred they're mitral regurgitation would get well enough that they didn't qualify. Once they'd really aggressively jacked up their medical therapy. But for the people that qualify for it, it has clearly been shown to have benefits in terms of symptoms. And, you know, lower rates of progression and needing L've at or transplant. And one of the challenges is much like a lot of things. How do we really predict who's going to do well and in whom is it, um, or futile procedure? Uh, there was a great study out of Italy looking at using a pulmonary artery. Pulse it Il Ity Index, which is a marker of right ventricular function. If your RV is terrible, you're probably not going to do well. There's been ah lot of interest in using uh, cardiac M. R I, which provides much better. Three D quantification of the left ventricular volume regurgitate volume and is a much more accurate way to quantify the degree of my two regurgitation. And there's a lot of talk about whether it's proportional or disproportionate meaning. If your ventricles in large because you have heart failure, you're gonna expect some degree of my true regurgitation. The valve just doesn't. It's not big enough to cover that hole, whereas if you've got a relatively small ventricle and you have a lot of my tour vegetation, those might be more likely to benefit so much out there in terms of tech and devices and more on the horizon. Let's move on to talk about heart failure teams and cardiogenic shock, a heart failure response team or heart failure team. Can you talk to us a little bit about how that's gone for for your institution, your involvement in it as well as cardiogenic shock and where we're at with that? I think there's a couple different ways to look at this. The first is that team based care has really been an essential part of heart failure care, particularly in an outpatient setting, and that's been a big part of our program and our development that we've been really expanding. You know, there's a lot of people that touch heart failure patients in an inpatient setting. It's a little different. You know, we often have many of the same people involved in their care. Um, but, you know, depending on what hospital you're in and what the, um, structure of that hospital is Ah, lot of patients with heart failure nationally are admitted to hospitalists. You know, internist, family medicine. Not all hospitals have or, um, always use or need cardiologists. Um, some hospitals use cardiologists quite extensively, being a heart failure specialist. There's relatively few of us in the country, and certainly not enough that we can see everyone who gets admitted with heart failure. You know, we're bursting at the seams that there's six of us here, but that's, you know, most hospitals have none. Um, And so, you know, I think what's been a challenge is figuring out How do we all work together so that we're all, you know, working towards the same goals? How do we understand when someone needs other people involved in their care? Um, in the inpatient setting, the other parameter, and the other area that is kind of an entity unto itself, which is the cardiogenic shock patients. And there have been a couple of national initiatives to try to protocal eyes and have mawr sort of team based algorithm based care for these patients. Some of these are heavily dependent on the use of some temporary mechanical support devices. Um, and I think one of the advantages of these cardiogenic shock teams is that they often will bring in, uh, interventional cardiologists if they are present heart fire cardiologists, often surgeons and intensive ists or critical care specialists. Cardiogenic shock hasn't on the order of 50% inpatient mortality. Um, eso These teams have been a big part of that. There are some newer treatment modalities. ECMO or extracorporeal membrane oxygenation, thes air for people. Many of these patients, I would say most, if not all that are being put on ECMO are people that are are going to die if you do nothing. And if you provide that modality we've seen, you know, in excess of 50 60% survival. And this is not, you know, the cardiogenic shock. 50% survival. That's a different category, people. I mean, these are often people they're undergoing. Active CPR, have blood pressure of 50. Um, you know, purple modeled. They are. We're talking survival out of the hospital. 30 days. What s so it depends on how you slice it. And so a lot of it depends on how fast you can get them. Kanye Lated, for example, When I say cardiogenic shock has a 50% survival that someone who's sort of in the hospital meets the classic criteria for cardiogenic shock, systolic pressure less than 90 or you no need for pressers and organ dysfunction being attended those kinds of things. Even that group has a 50% survival. So when you start throwing on out of hospital arrest or people that need ECMO now you're talking about, you know, these air groups that, absent these types of modalities, may have an 80% chance of dying. You know, when we get into cardiogenic shock or just completely exhausted, everything else that we haven't touched on yet is l VOD, And when is when is that implemented? Historically, they've been characterized either by use as a bridge to a heart transplant or what is often called destination therapy. That's for people that are ineligible for transplant. Those can fluctuate, um, other than if you are, let's say, 75. We rarely offer transplant past siege of 70 If you get Anel VAT in your 75 you will live the rest of your life with that. L've add in all probabilities when the recommendation for transplant, when you too. I mean, obviously it sounds it sounds pretty. I mean, it's it's fairly definitive, as far as I think. The ominous Well, it's It's a great question, I would say. First of all, you know, the outcomes. They're quite good. I mean, there've been well over 100,000 transplants done worldwide. Outcomes are in excess of 90% survival in a year and 50% survival a 10 years. So I often tell people, you know, this might sound like a death sentence, but compared to what you're facing with heart failure, this for many people is a very good option of giving them a very good quality of life. There are some objective parameters. We do try to use exercise testing to sort of confirmed that their heart is indeed sick enough. Um, that that this would make sense. Um, and then we look for reasons that they might be have contra indications or reasons that make it look like it would be too risky. Um But I would say both Elvin and Transplant. We often couple these as advanced heart failure options. And so these air, often for people that have had, you know, whether it's repeated hospitalizations, refractory symptoms can't tolerate medical therapy. Anything else that you'd like for us to know about the heart failure program and do you guys have is Are there any tools or resource is that we can access that you'd like to put a plug in for Thank you. You know, I think we've got a program that offers really the full spectrum of heart failure care on dso were, you know, eager to help in any way. Um, we have busy and growing program with our advanced practice providers helping with medication tight rationing, diuretic optimization. You know, we have access at many sites in the metro area and in remote access at many sites outside of the metro area. We're happy to see people at any time. I I have often found that no one's disappointed to hear you're doing great. You don't need Anel VOD. They dance out of my office. But we you know, we do have patients that come and say, Well, I didn't know there was someone that specialized in heart failure. And where I often will say, I wish I had seen this person sooner is someone who is not on enough of the medications they're gonna even on treatment. They're gonna eventually have problems. But we can often delay that quite a bit. Thanks so much for your time today, Dr Eggman. Thank you is a lot of fun. Dr. Eckman and his team at Minneapolis Heart Institute are here for you and your patient's heart failure and advanced heart failure needs. So feel free to reach out to him and the folks here at M H I. Thanks for joining the conversation today with Dr Eckman, and we'll see you next time on cardiovascular conversations. Take care. Thanks for listening to cardiovascular conversations with Minneapolis Heart Institute. If you haven't already done so, be sure to subscribe to the podcast and for lots of excellent clinical tools. Be sure to check out the APP for Minneapolis Heart. For more information, please also visit Minneapolis Heart Institute at Minneapolis heart dot com. That's mpls heart dot com. And don't forget to review us a swell. This is Jason Hicks and I'm Fred Meuse signing off until next time. See you soon. Mhm Use A reproduction of cardiovascular conversations is forbidden without the express written consent of Minneapolis Heart Institute or a line of health. Cardiovascular conversations should not be used for legal purposes, and it does not take advertising money. The content is informational only and is not to be used as a substitute for medical decision making or as medical advice. Some of the opinions of the hosts and guests are their own and not those of Minneapolis Heart Institute, Carolina Health.
