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- Hello, and welcome to House Calls: Real Docs, Real Talk.
I'm your host, Marcedes Fuller.
Today we're going to take a deep dive
into the new heart failure guidelines
that the American Heart Association just released.
These new guidelines wIll have a profound impact
on the healthcare landscape.
So let's get started.
With me this morning is Dr. Biykem Bozkurt.
She is the Professor of Medicine
at Baylor College of Medicine in Houston.
Welcome Dr. Bozkurt,
it's great to have you this morning.
- Thank you.
It's a great pleasure for me to be here.
- Absolutely. Let's get started
with some health in the headlines.
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Good health is always newsworthy
so each week we select one current headline
that ties back to the topic at hand,
we bring it back to our table
and we ask our expert to respond.
This week's entry comes to us from CNN
and the headline reads, "New heart failure guidelines
add another type of meds to treatment recommendations."
Dr. Bozkurt, what's the new medication
and how does it all fit in?
- Thank you.
It's exciting that we now have
four classes of medications, which now includes
sodium-glucose co-transporter 2 (SGLT2) inhibitors.
These medications prevent reabsorption of glucose
as well as sodium in the kidneys.
They were initially used by diabetologists
for glucose lowering in patients with diabetes.
But we now have found out that they are quite beneficial
in heart failure, regardless of diabetes,
even in patients without hyperglycemia or diabetes.
They have beneficial effects in heart and the kidney,
and now they're part of the armamentarium
for standard therapy of heart failure.
So SGLT2 inhibitors along with beta blockers,
mineralocorticoid receptor antagonists,
and renin-angiotensin inhibitors,
which include ARNI, ACE-inhibitors or ARB
are now indicated as first line therapy for patients
with heart failure with reduced ejection fraction.
They reduce cardiovascular mortality
and heart failure hospitalization,
and should be prescribed in all patients with heart failure
with reduced ejection fraction.
- Sounds like so much great advancement that's happening.
I get excited when I hear about medical advancement.
So thank you so much for highlighting that for us.
Let's get into our main segment and we call this segment,
You Ask, We Answer.
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Doctor, there are so many questions that are coming in.
People are eager to hear about the updated guidelines.
So let's jump in.
Our first question, it comes to us from Malia in Chicago
and this is what Malia wants to know.
How will the new heart failure guidelines
improve patient care?
- The guidelines provide clear recommendations
for evidence-based therapies and management
that result in improvement in clinical outcomes.
These recommendations when implemented they save lives,
they prevent progression of heart failure,
they prevent heart failure hospitalizations.
Thus there is an urgency and necessity
to optimize therapies,
even in patients who may appear stable.
When patients have active heart failure,
outcomes are as bad as cancer.
Therefore there is a need to optimize these therapies
to prevent future adverse outcomes.
And we have recommendations
for different types of heart failure,
including those with heart failure
with reduced ejection fraction,
as well as mildly reduced ejection fraction
and preserved ejection fraction,
as well as we have specific recommendations
to prevent heart failure
in addition to treatment of heart failure.
Thus we want to alert patients as well as all clinicians,
it's more important than ever
for the guideline directed therapies to be implemented
and optimizing all heart failure patients.
- And doctor, while we're speaking
on the the stages of heart failure,
there's a question that came in from Sasha,
and she wants to know what are the stages of heart failure.
- Thank you for that question.
The stages include patients at risk for heart failure,
pre-heart failure, heart failure and advanced heart failure.
Patients at risk for heart failure
are those who do not have symptoms and/or signs
but are at future risk for heart failure.
Pre-heart failure is when patients
do not have symptoms or signs,
but may have abnormal cardiac function or structure
or abnormal cardiac biomarkers.
Heart failure is when the patients have symptoms or signs
attributable to abnormal cardiac function or structure.
Advanced heart failure is when patients have
advanced symptoms requiring repeated hospitalizations,
referral to advanced care,
and may need higher levels of care.
We have specific recommendations for each stage
including for patients at risk,
as well as pre-heart failure
to prevent future development of heart failure
in addition to specific recommendations for heart failure
and advanced heart failure.
Our aim is to reverse the trajectory
and prevent development and progression.
And it's exciting that we do have
effective, useful strategies to detect,
prevent and treat heart failure.
And this, armamentarium actually will empower
the clinicians to diagnose heart failure in a timely manner
and prevent before it gets quite advanced.
- Very good.
Doctor, we have another question that's coming in
and the question is from Chelsea in Arkansas
and this is what she wants to know.
What is the difference between reduced ejection fraction
and preserved ejection fraction?
- Ejection fraction is a measurement
of how well the pump can squeeze
and eject blood that fills the the heart chamber.
An injection fraction higher than 50% is considered normal.
One below 40% is considered reduced.
So ejection fraction between 41 and 49%
is now considered mildly reduced.
When heart failure symptoms and/or signs occur in a patient
with ejection fraction exceeding that of 50%,
we call that heart failure with preserved ejection fraction.
When heart failure occurs in a patient
with ejection fraction less than 40%,
we call that heart failure with reduced ejection fraction.
When heart failure occurs in a patient
with ejection fraction between 41 and 49%,
we call that heart failure
with mildly reduced ejection fraction.
- Here's a question from Hunter.
What are the types of medications that could be prescribed
for a heart failure patient with reduced ejection fraction?
- Guideline directed medical therapy
for symptomatic heart failure patients
with reduced ejection fraction now includes
quadruple classes of medications
which include the SGLT2 inhibitors, beta blockers,
mineralocorticoid receptor antagonist,
and RAAS inhibition with ARNI
in NYHA class II-to-III heart failure
or ACE-inhibitors or ARB in NYHA class II-to-IV
heart failure patients.
In addition to these core therapies,
diuretics are recommended as needed for patients
with fluid retention to relieve congestion.
Once these first line therapies are optimized
additional therapies can be considered.
Hydralazine and nitrates are indicated in African-American
or black patients and other therapies such as
Ivabradine can be considered for patients
with elevated heart rate despite optimal doses
of beta blockade, digoxin,
or soluble guanylate cyclase stimulator
may be considered to reduce
heart failure hospitalizations in certain patients.
We also have specific recommendations
for patients with mild reduced EF and do recommend
the continuation of guideline directed therapies
even among those patients who have improvement
in their ejection fraction.
- Here's a question from Beau in Delaware.
What role can caregivers play
in a heart failure patients management of their condition?
- This is a very important question.
Caregivers are critical part of the heart failure journey
and caregivers need to be aware that there are therapies
that can improve symptoms, functional capacity,
quality of life as well as survival
and reduction of hospitalizations for their loved ones,
for their patients that they provide care for.
Caregivers can help patients receive optimized care.
They can help translate that the number of medications
should not be something that the patient should be afraid of
but rather see as an opportunity to beat heart failure.
And caregivers can also help navigate and coordinate
the transitions of care, especially post discharge
or coordination of follow-up appointments.
They can also help implement lifestyle changes,
help patients remain physically active.
Caregivers can also help with identification
of patient goals,
which is central to all our treatment options.
It's a critical concept
that needs to be conveyed to all providers,
including specialists as well as primary care providers.
And caregivers can also help coordinate
the management of comorbidities.
In the new guidelines, we have specific recommendations
for management of diabetes, hypertension,
sleep apnea, iron deficiency, atrial fibrillation,
cancer therapy related to heart failure
as well as valvular heart disease.
So I think we have many more guideline directed therapies
that is gonna help our patients
in the whole continuum of care,
in the whole heart failure journey.
- Doctor, I'm so excited about these new guidelines
because it seems like it's a wealth of information
that will really help so many patients.
Jenna from Austin wonders,
is there any medication for heart failure patient
with preserved ejection fraction?
- We do have specific recommendations
for patients with heart failure preserved ejection fraction.
SGLT2 inhibitors now have a class 2a recommendation
in patients with heart failure with preserved EF.
They can be beneficial in reducing
heart failure hospitalizations and cardiovascular mortality.
Mineralocorticoid receptor antagonists,
angiotensin receptor blockers and ARNI
have a class 2b recommendation
and maybe considered to decrease hospitalizations.
We also have specific recommendations
for treatment of hypertension,
as well as treatment of atrial fibrillation
and cardiovascular disease in patients
with heart failure with preserved ejection fraction.
- Barbara wants to know what role can a specialty care team
serve for a patient with advanced heart failure?
- Patients with advanced heart failure
who wish to prolong survival should be referred
to a team specializing in heart failure.
A heart failure specialty team
reviews the heart failure management,
assesses suitability for advanced heart failure therapies
such as mechanical circuitry support,
palliative care, cardiac transplantation and others.
So coordination of care with the specialty team
will help appropriate implementation of guideline
directed therapies and tailor the therapies
to patients goals.
- Our last question comes to us from Caroline
and this is what she wonders.
Why is primary prevention important for those at risk?
And what are the recommendations for prevention?
- Primary prevention is critical to prevent heart failure
especially for those patients who are at risk
such as those patients with hypertension, diabetes,
coronary artery disease or obesity.
We do have specific recommendations for these patients
which include optimal control of blood pressure
in patients with hypertension,
SGLT2 inhibitors in patients with diabetes
to prevent cardiovascular disease or heart failure risk,
optimal management of cardiovascular disease,
multidisciplinary evaluation in patients
with exposure to cardiotoxic agents,
genetic screening and counseling in first degree
of relatives of patients with genetic
or inherited cardiomyopathies.
For patients at risk for development of heart failure,
we also have a class 2a recommendations
for natriuretic peptide-based screening,
a biomarker based screening followed by team-based care
which can be useful to prevent
development of heart failure or cardiac dysfunction
especially among patients at risk for heart failure.
- Dr. Bozkurt, thank you so much
for sharing your expertise on the new guidelines.
Is there anything else that you'd like to add
before leaving us today?
- These new guidelines highlight
very critical recommendations
that are important in heart failure practice.
We're hoping that these new recommendations
will be helpful to clinicians, patients, and caregivers
to help us improve the patient outcomes.
- Thank you so much, doctor.
Well, friends that does it for our show today.
You can find any of our previous episodes
by visiting our YouTube playlist
and please make sure you subscribe
and share it with all your family and friends.
And we want you to stay abreast of all breaking health news.
Until next time, please take care of yourselves
and watch this closing video to refresh your memory
on the warning signs of heart failure.
We'll see you next time.
- [Announcer] Do you know the symptoms of heart failure?
During heart failure,
the heart can't pump blood efficiently enough
to meet the body's needs because either
its pumping ability has weakened
or because the lower left chamber has become thick
and no longer holds enough blood.
Without proper pumping fluid can build up and cause symptoms
that everyone should learn to recognize.
Swelling also known as edema is most often noticed
in the feet, ankles, legs, or abdomen.
Sudden weight gain.
People with heart failure can also track their weight
to help manage any swelling.
Shortness of breath is another important symptom
to discuss with your doctor,
especially if you notice that normal activities
are getting harder to do or that your breathing
is often interrupted by persistent coughing or wheezing.
You should also speak with a healthcare provider
if you lose the ability to sleep
and breathe well while lying down.
Inadequate blood flow can also cause lightheadedness
or fatigue, confusion, depression, or even fainting.
Additional symptoms can sometimes include
a rapid heart rate, nausea or lack of appetite.
If you notice these important symptoms
be sure to seek medical care.
Know the symptoms so that together
people who have heart failure can track symptoms
to help manage it successfully for a longer, healthier life.
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- [Narrator] Learn more about
House Calls: Real Docs, Real Talk
and submit your questions at heart.org/housecalls.