In this episode of Kentucky Health, Dr. Wayne Tuckson welcomes Dr. Stephanie Moore, a cardiologist with UofL Health and the medical director of the Advanced Heart Failure Therapy Program, to discuss diagnosing heart failure and innovations to treat the chronic disease. Here are three key takeaways from the conversation:
1) Heart failure affects over 6.5 million Americans, and it is a chronic disease.
A healthy human heart beats more than 100,000 times a day and pumps over 2,000 gallons of blood throughout the body to nourish all other organs and sustain life. For persons with heart failure, the heart is weakened and loses its ability to pump blood effectively.
“When somebody tells you, ‘You have heart failure,’ that should grab your attention,” Dr. Moore says. “We never want that organ to fail… There’s no turning off your heart.”
One in four Americans will be diagnosed with heart failure at some point during their lives, Moore says. She notes that diabetes and hypertension are the most prominent risk factors for developing heart failure, which account for half of the patients diagnosed.
“It happens as you get older, it’s more associated with hypertension, coronary artery disease, valve disease – older people things – but it can happen (earlier),” Moore says. “My last patient that I saw before coming here is 39 years old.”
Having a family history of heart failure also increases one’s chances of being diagnosed. Research conducted over the past 20 years has helped cardiologists connect certain genes to heart failure, Moore explains. Now, around a third of patients who are diagnosed with the disease but do not have hypertension or diabetes are found to have a genetic component as the cause.
“Just because you have the gene doesn’t mean you’re going to get heart failure,” Moore says. “You can have the gene, but the gene needs to turn on.” Moore and her team will ask patients about any family history and then swab the inside of the mouth for saliva testing. Patients who do have genetic predisposition but do not have heart failure are urged to follow a healthy diet and exercise regularly to ward off hypertension, diabetes, and/or coronary artery disease, any of which can “trigger” the gene, according to Moore.
The main symptom of heart failure is shortness of breath, which can occur even when lying down. This is caused by edema, or fluid accumulating in the lungs. The fluid can also build up in the ankles or abdomen, Moore says. Fatigue caused by this shortness of breath and fluid buildup is also a symptom, along with arrythmia.
Some persons with heart failure are able to engage in routine physical activity and lead relatively normal lives, but the disease has different stages. “Just because you (are diagnosed with) heart failure does not mean that you are failing,” Moore says. “It’s a chronic condition that needs medication and needs attention, and it’s very common because all of the risk factors are very common.” Those with advanced-stage heart failure comprise around 15 percent of all patients and are severely limited in what they can do.
2) Diagnosis of heart failure is fairly simple, and the list of preferred medications for treatment is short. Innovations in treatments beyond medications are ongoing.
Moore says heart failure is diagnosed in the clinic and begins with examining the patient’s neck, to see how the carotid artery is functioning.
“We listen to your lungs, we listen to your heart, we take your pulse, we do our exam – and then we (review) your history, if you’re short of breath when you walk. We should be able to tell by physical exam if someone has heart failure,” she concludes.
If a lab test is needed, however, Moore says a heart ultrasound called the echocardiogram is the gold standard. This test will measure the heart’s pumping capacity, called the ejection fraction, which needs to be at 50 percent or higher to be effective. If the underlying cause of heart failure is discovered in the echocardiogram – stiff arteries or a leaky heart valve, for example – the cardiologist and team will try to address that issue.
Four basic medications are used to treat heart failure, Moore says. These drugs block hormones sent from the kidney that, in patients with heart failure, signal it to work less efficiently, which will lead to dilation of the heart muscle, lower ejection fraction, and eventually fluid buildup elsewhere in the body. Once these medications take hold, the patient’s heart will, as Moore explains, “reshape itself” and function again.
If patients are unresponsive to these medications, Moore says the best remaining options are a heart transplant (Louisville is a national leader in doing them) and heart pumps. These pumps, called left ventricular assist devices (LASDs), are small in size and are surgically implanted into the heart muscle in the lower left chamber (ventricle). The device has an outflow graft to the aorta, which is the main vessel transporting blood to the body.
“It provides five liters of (blood) flow and assists your heart, which might be able to do one or two liters on its own, to the rest of your body,” Moore explains. The LASDs run on batteries which patients can carry in a vest, fanny pack, or other clothing accessory. “It does not stop you from living your best life,” she says. “The only thing you cannot do is swim.”
Moore says many of her patients using LASDs are living 10 years or more with the devices, and the technology is improving. “The beauty of it is you take away a lot of the medications you normally have to take,” she adds. “A transplant is wonderful – it is a gift, it is a miracle. But there is immune suppression. The pump doesn’t (cause) immune suppression, require any biopsies, or anything like that.”
To qualify for a heart transplant, Moore says that a patient has to have failed medical therapy, have an ejection fraction rate of less than 25 percent, show significantly reduced function via a specialized stress test, and then undergo a heart catheterization procedure to prove that the lungs are working normally. “For a transplant to be successful, you have to be healthy otherwise,” she says.
3) The best treatment for heart failure is to avoid getting it.
With very few exceptions, a person diagnosed with heart failure will become worse over time, although as noted above there are effective ways to slow this progression.
Humans are more susceptible to developing heart failure as we age, Moore acknowledges. “But you know what – keep going. It’s going to happen, it’s called wear and tear, but you can prevent the ailments of aging,” she reasons. “Keep moving, eat a vegetable, stop smoking, or don’t start smoking. That’s my big thing.”
Moore stresses that people don’t have to achieve triathlon-level fitness to keep their hearts healthy. Moderate, regular exercise will do the trick. “You have to use your tennis shoes,” she says. “It’s simple walking, getting your steps in. Do not be sedentary.”
She also encourages persons diagnosed with prediabetes to make the necessary dietary and lifestyle modifications to prevent or delay getting Type 2 diabetes. The same goes for those whose blood pressure readings are getting progressively worse. Reducing salt intake and eating more vegetables are two necessary changes, and Moore urges those who use tobacco to sign up for cessation programs.
“It’s amazing, if you do some of this stuff, say you cut out soda, say you cut out snacking, say you decrease salt (intake), now that’s not too hard… and you say, ‘Every day, I’m going to walk a mile.’ You will change in 12 little weeks,” Moore says. “It’s amazing how much your body wants to be healthy.”
