What is heart failure, and what are the newest options for treatment and care for heart failure patients? Dr. Ron Falk interviews Dr. Patty Chang in this podcast about heart failure. Dr. Chang is an Associate Professor of Medicine in the Division of Cardiology at the University of North Carolina. She directs the Heart Failure and Transplantation Program as well as the Advanced Heart Failure and Transplant Cardiology Fellowship Program at UNC.
“..If we had donor hearts for everybody who needed a heart transplant, we could be doing transplants for 200,000 people a year in the United States. But the reality is, it’s about 2,000 lucky patients per year..who get a heart transplant.
-Dr. Patty Chang
Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair’s Corner.
Today we welcome Dr. Patty Chang who is an Associate Professor of Medicine in our Division of Cardiology. Dr. Chang has special expertise in heart failure and transplantation, and she directs the Heart Failure and Transplantation Program at UNC. She is also the Program Director for the Advanced Heart Failure and Transplant Cardiology Fellowship, which is designed to teach trainees all about heart failure.
Today, we are going to be discussing heart failure- latest research and treatment options, and some of Dr. Chang’s work in this field. Welcome, Dr. Chang.
Chang: Thank you, Dr. Falk.
Falk: Help me understand what it is like to have heart failure, if I’m a patient with it.
Chang: Heart failure is becoming increasingly common, and what we mostly see are patients with symptoms. Those who have symptoms are mostly a combination of shortness of breath, or fluid retention, or swelling. If they’re short of breath they’re usually not able to do what they used to do, so decreased exercise tolerance. If they have fluid retention like swelling, they often see it in their legs, or feel like their belly’s really bloated, or sometimes or often time their shortness of breath is caused by fluid in the lungs.
Falk: Fluid in the lungs, or swelling in other parts of the body, especially legs, can occur in liver disease, it can occur in kidney disease. How do you know it’s heart failure?
Chang: It’s a great question, because we don’t always know that it’s heart failure. Sometimes it takes a while to come up with the diagnosis, but the first thing one should think about is if their symptoms are not known to be anything else, or even if they have liver disease, it’s probably worth making sure that their heart’s in good shape. A very simple test, like an ultrasound of the heart – the echocardiogram – can give a clue about the heart function, and when the heart function is reduced, we call that reduced ejection fraction, or systolic dysfunction. That’s often a sign that the symptoms are from heart failure with reduced ejection fraction.
Falk: So what does ejection fraction mean?
Chang: The heart is a muscle that pumps blood to the rest of the body, and how much comes from the heart to the rest of the body is calculated as an ejection fraction. How much the heart ejects forward to the rest of the body. A normal ejection fraction is over 50 or 55 percent, so anything less than 55 percent is considered low, or reduced, and there’s different severities among that.
Falk: If I were a trained athlete—which I’m clearly not—what would my ejection fraction be? If I were ready to go to the Olympics or have just come from it.
Chang: That’s a great question because there’s a variety for athletic hearts too. But I think most athletes are at least above 50 percent, but some athletes are 70 percent. Some are 50 percent, but they should not be low, lower than 50 percent.
Falk: If my ejection fraction is lower than 50 percent, and I have shortness of breath, and swelling in my ankles, I may have congestive heart failure.
Chang: Right. One should make sure you’re checked out for that.
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Transcript continues below. See individual tabs to jump to specific topics.
Falk: What causes congestive heart failure? Why would I get it?
Chang: There are so many different causes. It’s not due to just one disease, but we often describe it as a syndrome that results from any disease that impairs the function of the heart. That’s mostly a function of its ability to eject—contract or squeeze, as we often say. When it doesn’t squeeze well, or contract well, that ejection fraction is low. There’s also a type of heart failure where the ejection fraction is normal or preserved, and that’s called heart failure with preserved ejection fraction – previously known as diastolic heart failure. Often, what’s related to that is that the heart is so stiff, it doesn’t relax well enough for the blood to go forward, so the blood goes backwards.
The etiologies (causes) for either of those are quite vast. The number one cause in the US is coronary heart disease, or coronary artery disease, often from heart attacks or blockages in those coronary arteries. The second most common cause in the US is probably high blood pressure. So treating high blood pressure adequately through the years is very important to prevent this heart failure syndrome.
Falk: How about treating cholesterols?
Chang: Cholesterol contributes to coronary disease for sure; whether it contributes to heart failure is less clear.
Falk: And presumably I’ve already stopped smoking or never smoked in the first place, because that would contribute to coronary artery disease as well.
Chang: That’s right. People who are at higher risk for heart failure are those who’ve had smoking, higher cholesterol, who have also had lower educational status or socioeconomic status, mostly because it’s all related to coronary risk factors. But in addition, valvular heart disease, murmurs that go out of control or aren’t fixed in a timely manner, if they become severe valve disease, they can lead to heart failure also.
Treatment and lifestyle changes
Falk: When you see these people for the first time, and you know their ejection fraction is abnormal or there’s something else wrong with their ability to have forward blood flow—what’s the first thing you’re going to suggest?
Chang: Most likely, they have these symptoms because they are full of fluid in their lungs or have fluid in their lungs. Often times, relieving that fluid by getting rid of it with diuretic medicine will do the trick.
Falk: Something like furosemide, bumetanide, one of those.
Chang: Right. The most common diuretics are called loop diuretics like furosemide, bumetanide, torasemide, or Lasix, Bumex, Demadex for the trade names.
Falk: Also some lifestyle modification to start with. Makes no sense to go eat a whole bag of salty potato chips when you’re using a diuretic to try to get out salt and water.
Chang: That’s right. In fact, the number one advice that we could give to really impact patient wellness is their own ability to control their symptoms by diet and exercise. We don’t want them to be sedentary and become couch potatoes, but at the same time, we want them to be very cognizant of their sodium or salt intake, and their water or fluid intake. Because we live in North Carolina—lots of people love sweet tea and BBQ, and that combination gets to be very difficult for the heart failure patients because they really can’t drink all that much and they cannot really eat that much salt.
Falk: After you’ve done lifestyle modification and put them on a diuretic, anything else one can do?
Chang: Absolutely. Our field in medicine in general has evolved so well to note that certain medicines are so helpful to either stop the progression of heart failure, or maybe improve the heart function over time. These medicines are various classes which block various hormones in the body. They include beta-blockers, ACE inhibitors, also known as angiotensin converting enzyme inhibitors, a cousin of that known as angiotensin receptor blockers or ARBs. Another class is aldosterone blockers.
And we have a brand new drug that has made the heart failure professional community very excited, and that just came out last year, which was a combination drug of ARB with a neprilysin inhibitor. We call that ARNI for short because you know that cardiologists love abbreviations and acronyms! That is a new drug that seems to be the biggest thing since aldosterone blockers in heart failure and may be yet another tool in our kit to stop the heart failure from progressing and maybe improve survival.
Falk: What do you tell to patients who are on a number of medications? How do you have them remember what medicines to take when, and to avoid some of the side effects that may be bothering them?
Chang: Very difficult, and a good question, because it’s not just the doctor that is involved. It’s really a team of care providers, including the nurses that they interact with, pharmacists that work with us, and ultimately the family. We really want to encourage the patient and their social support to help them figure out how to take their medicines right. When we teach them about the medicines, it’s often about, “Well this is for your heart in general,” or “This is for your fluid management,” and if we need to develop a schedule for you, or use pill boxes to remember. We try to educate them as much as possible about which medicines are for what, but in the end, it is a lot of medicines for patients to take, and it becomes a little difficult. That’s why sometimes getting their family member to help out helps as well.
Falk: So caregivers or family members in general are instrumental in making sure that these patients do well.
Chang: That’s right. Caregivers are the key to success. We’ve had lots of people at UNC, faculty at UNC, investigating this topic, who I’ve collaborated with to show that family members and caregivers can really provide important support to improve outcomes.
Research at UNC in risk factors & in pregnancy
Falk: You’ve done a lot of research in two general areas. One pertains to risk factors that are involved in developing congestive heart failure, and also in terms of how patients do long-term. Let’s start with the risk factor studies you’ve been doing. Can you tell us a little bit about those?
Chang: Sure. My focus in that area has particularly been in the atherosclerosis risks in community study, of which UNC is the coordinating center. This is a study that’s been following residents in four different communities for over thirty years, including a site in North Carolina—Forsyth County. We have seen various associations over the years. These include, as we talked about before, hypertension, even if you prevent a little bit of a drop in the systolic blood pressure, that will not only reduce the risk of coronary artery disease, but reduce the risk of heart failure. Or the converse—you increase the blood pressure more, the higher the risk for heart failure. We’ve seen various other associations of, say, lung function or maybe even orthostatic hypotension, which has been curious. We certainly know that socioeconomic factors, especially low socioeconomic status is associated with worse risk for heart failure.
Falk: How about outcome? How do you tell somebody, “You’re going to do really well,” or maybe you’re not going to do well? What are the determinants there?
Chang: We just recently looked at factors of medication adherence, and that certainly makes a big difference. As much as people can adhere to medications, and see their care providers in the medical setting, that will help them a lot.
Falk: You also have studied a very special population of patients who develop heart failure, and those are individuals who are pregnant. You get, in some patients, heart failure associated with pregnancy. How does that happen?
Chang: It’s a very difficult situation, and fortunately, relatively rare. That condition is called peripartum cardiomyopathy.
Falk: “Peri”—“around,” pregnancy, in other words.
Chang: That’s right. Peripartum being around the time of pregnancy. We define that fairly strictly to say if they have no other cause for heart failure, it occurs in the last trimester of pregnancy, or up to five or six months after delivering. Again, it’s a diagnosis of exclusion with the hope that there wasn’t something else causing their heart failure. Often times, it can be reversible with good medical therapy, and in some cases it progresses very rapidly.
Falk: Does it result in early birth, or otherwise altering the course of the pregnancy?
Chang: Sometimes it does, if the mother is very symptomatic. Often times it doesn’t really affect the child so much, unless there’s an issue requiring the child to be born earlier, but that’s pretty uncommon.
Falk: What causes heart failure in an otherwise healthy, young person?
Chang: We don’t really know. I think it’s still to be determined, but there has been some research to suggest that maybe there is an abnormal form of a prolactin-related peptide in those who have this peripartum cardiomyopathy. It’s still under investigation on how much we need to pay attention to that potential pathophysiological mechanism, but what we have observed otherwise is various clinical risk factors such as, a woman who is classically more multiparous, or having had multiple pregnancies. Maybe having more than one child or having multiple gestations, they often might be older, and of African descent, and hypertension, either pre-existing or at the time of pregnancy.
Falk: You take care of a lot of patients who need a heart transplant or who have had a heart transplant. Who ends up needing a heart transplant, and how well do people do after they’ve finally gotten one?
Chang: I think if we had donor hearts for everybody who needed a heart transplant, we could be doing transplants for 200,000 people a year in the United States. But what the reality is, it’s about 2,000 lucky patients per year in the United States who get a heart transplant, and who ends up needing it are those who really have progression of heart failure and are considered good candidates for heart transplantation, which often means, what makes them not a good candidate is things like being too old for a transplant, having too many comorbidities that prevent having the heart transplant. Also it’s very important that these patients have adequate social support, so that they can survive well and happily, after heart transplant.
For those lucky 2,000 per year in the United States who get it, generally they do very well and resume a normal life. I can proudly say that several of my favorite patients have become great spokespeople for heart transplantation in general by demonstrating what they can do after transplant. One has run several 5K races, climbed mountains in Canada, and was really a true role model for others having lost a hundred pounds after heart transplant. And he sends us pictures every now and then to thank us, to thank really the greater communities for his great gift of life. We’ve also had a terrific spokesperson who was a nurse herself who ultimately had a heart transplant. She’s been a terrific spokeswoman for women with heart disease, and therefore women who need heart transplant.
Falk: Some patients aren’t lucky enough to get a heart transplant, and so they have an artificial heart. What’s an artificial heart, and how well do those work?
Chang: Technology is really great. These artificial hearts are now called Ventricular Assist device, or Left Ventricular System Device, to really support the left ventricle, or the left side of the pumping chamber of the heart. These LVADs really can sustain patients for years. They are a sort of heart pump or heart bypass machine to allow the body to function relatively normally for as long as that machine works.
Falk: How functional are those people?
Chang: These people are almost normal, except that they have some limitations, because it’s a heart pump that requires electricity, they will have a driveline that comes out of the body to connect them to a power source. So they can’t go swimming, they can’t take a bath, but they can certainly shower, and walk along the beach, and be careful with everything they do to make sure their driveline is nice and safe. But ultimately they’re doing everything they want to do outside of the water as long as they’re keeping their pump and driveline relatively safe. That includes running, that includes dancing, that includes doing whatever type of races they want to do too.
Falk: A heart transplant though is a better long-term possibility for those who get a transplant and are medically capable of getting one. Is that right, or is the technology so advanced that they’re almost equal.
Chang: Well, we all have biases, and I will share with you that my bias is that still, tissue is better than a machine. Ultimately the machines are going to catch up. At this point, many of us still think that the heart transplant is better because it’s durable. But you trade one set of problems for another and after heart transplant, there may be potential complications that the patient has to be vigilant about to prevent future complications or other problems related to transplant. But the machine, very simple. It’s a machine, you don’t have to take 20 pills in the first month after implantation, but the machine doesn’t last forever. Eventually, we think these machines will last very, very long. We’ve heard of some of these LVADs supporting patients for ten years or more, and when the driveline gets internalized, and it’s all inside the body like a pacemaker or a defibrillator, maybe that’s when they can really last just as long as a heart transplant.
Specific advice for caregivers
Falk: Other than being present, other than being in the house, what specific advice would you give a caregiver?
Chang: I think caregivers can be really a representative for the patient, to not only care for them and make sure they’re doing well, but report for them, follow their symptoms, track their symptoms, help communicate with their medical care providers as needed. Bring them to appointments, support them during these difficult times when the heart failure gets symptomatically worse, or their prognosis becomes worse, or they’re experiencing more complications from their heart failure.
Falk: How do you convince a caregiver to speak up at a doctor’s appointment?
Chang: That’s a great question, because I think this is the art of medicine. You get both scenarios: sometimes the caregiver doesn’t say anything, and other scenarios where the caregiver does all the talking. There’s probably a happy medium between the two. Ideally with the patient talking the most. I think it’s very important to recognize the caregiver in the room and say to the patient, “May I ask your family member or support person here other questions? Or to chime in if they have any other thoughts?”
Falk: I typically want to talk to especially the spouse because usually a spouse will tell you far more about what’s going on than patients do.
Chang: That’s right, and especially patients who tend to minimize their symptoms, and that’s where we get into the most trouble, when the patients don’t want to share how terribly they’re doing, but the spouse or caregiver says, “Oh, well that’s not how it goes in our house.”
Falk: Right. The truth eventually comes out. It’s always better for the patient and the caregiver.
Falk: Where would a caregiver, where would a patient get up to date useful information? Are there organizations that you would point patients to?
Chang: Yes, absolutely. We’re very lucky that there are a lot of professional organizations that support heart issues and cardiology in general, and then particularly heart failure patients. For example, there’s the American Heart Association, which is probably the largest professional organization for heart issues. The AHA has a very specific web site that is directed to caregivers to provide them with a support forum, and to give them some useful tips about how to become a caregiver. There’s also a similar society called the American College of Cardiology that would have similar resources. A specific professional organization would be the Heart Failure Society of America, and they really provide great resources, not just for professionals like the physicians, nurses, and other caregivers in the medical setting, but particularly for the patient and their caregivers for specific lifestyle instructions and advice, some explanations about the medications that they take—really terrific resources there and I encourage people to look there.
Finally I think there has been a lot of interest among patients themselves to support each other. We certainly know of smaller societies that are patient-focused, that are disease-specific—there’s one called the Myocarditis Foundation. Then those who have LVADs—they have their own web site, an organization called MyLVAD.com. There are support groups that are very active on FaceBook and other social media to help support each other.
* Update – Dr. Chang recorded a special episode focused on heart transplant, which was posted December 2017.
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