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Talking to Your Doctor About Heart Failure

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Written by Todd Neff on behalf of National Jewish Health
It’s never too early to talk to your doctor about heart failure. The question is do you talk with your primary care physician or a cardiologist? And what do you talk about?

About 80% of heart failure patients get treated solely by their primary care physicians, says Ankie Amos, MD, a National Jewish Health cardiologist specializing in heart failure. That’s a good start, she says. But it’s not enough for most heart failure patients.

Heart failure has many roots. The most common cause is when fat and cholesterol cause hardening of the arteries. Other causes of heart failure include high blood pressure, heart valve disease, inflammation and congenital heart defects. These can lead the heart to weaken through four stages of decline.

Here are four important things to talk about with your doctor.

1) Get to know the risk factors for heart failure and work with your doctor to address them. 

Some risks you can control. The big ones are:

  • Smoking

  • Excessive drinking

  • A lack of exercise

  • High blood pressure (hypertension)

  • Obesity

  • Diabetes

Other heart failure risks are out of your hands such as:

  • Being over age 65

  • A family history of heart failure

  • Having undergone cancer treatment

  • Having had a heart condition, heart attack or serious lung disease

2) If heart failure runs in your family or you’ve been diagnosed with it, request a referral to a cardiologist who specializes in heart failure.

Heart failure specialists can run a wide variety of tests to determine the type of heart failure you have and what stage of heart failure you’re in. Treatment will be different depending on both of these factors.

3) Learn about the dramatic advances in heart failure testing and treatment in recent years. 

“Everybody with a diagnosis of heart failure should see a specialist at least once to make sure they’re being aggressively managed,” Dr. Amos said.

There’s a reason for that. Recent years have seen many advances in heart failure diagnosis and treatment. Primary care physicians — and even general cardiologists — may not be comfortable prescribing advanced heart failure medications. They also may not have access to, or expertise in specialized testing, monitoring and medical devices.

“There is a narrow window in which a patient may be a candidate for advanced heart failure therapies,” explained Dr. Amos. “If they don’t have a heart failure specialist following their disease, they may miss that window, and their life may be shortened as a result.”

4) Understand the key treatment options for heart failure management and how those options change as the disease progresses. 

Medications are important when heart failure patients has symptoms such as:

  • Shortness of breath and/or discomfort with activity

  • Fatigue

  • Swelling of the lower legs or belly due to fluid retention

  • Chest pain

Patients should be familiar with what are known as the “four pillars” of heart failure therapy. The four pillars are medication categories that combine to regulate the body’s hormones in a way that takes pressure off the heart and helps heart failure patients live longer. The four pillars are:

  1. Beta blocker – cause the heart to beat more slowly, which lowers blood pressure

  2. Angiotensin receptor-neprilysin inhibitor (ARNI) – a two-drug combination that lowers blood pressure, opens blood vessels wider and gets rid of more sodium

  3. SGLT2 inhibitor – increase circulating ketones, which decrease oxygen demand and reduce the how hard the heart works

  4. Aldosterone receptor antagonist –prevents the reabsorption of sodium, which decreases blood pressure and fluid around the heart

“These medications can add 10 years to your life if you’re on all four, and they’re aggressively managed,” Dr. Amos said. “Patients should certainly ask, ‘Am I on all four? And if not, why not?’”

Aggressive management means making sure patients get the maximum dose they can tolerate. Because dosing often changes over time, ongoing visits with a heart failure specialist are a must.

Patients with heart failure with preserved ejection fraction (HFpEF, pronounced “hef-pef”) also have a medication option. According to Dr. Amos, that wasn’t the case until recently.

About half of heart failure patients have HFpEF. This happens when a heart that’s stiffened or thickened from scarring, amyloidosis, or other causes, pumps too little blood with each beat. A drug called tafamidis can stop the creation of misfolded proteins that infiltrate the heart and cause many cases of HFpEF. More HFpEF drugs are in the pipeline. Some HFpEF patients are already benefitting from one called mavacamten, which eases the heart muscle’s contractions in cases of heart failure caused by hypertrophic cardiomyopathy.

“HFpEF was a fatal diagnosis,” Dr. Amos said. “Now we have treatments, and even more are getting approved.”

Devices for Life

Medical devices also play important roles in heart failure treatment. Pacemakers help keep the left and right sides of the heart synchronized. The official name of this treatment is cardiac resynchronization therapy or CRT. Pacemakers also improve the heart’s efficiency and function.

Implanted defibrillators prevent sudden death from bad arrythmias (irregular heartbeats) due to heart failure.

The CardioMEMS monitoring device can constantly measure pressure in the artery between the heart and the lungs and report that to your doctor every day. That helps spot and address problems before they land the patient in the hospital.

A device called Barostim™ stimulates sensors in your body and can reduce the heart’s workload.

In advanced heart failure, where patients feel symptoms even at rest and hospitalizations become frequent, ventricular assist devices (VADs) help the heart pump blood. They can operate for years in cases where a heart transplant isn’t possible because of advanced age, a prior cancer diagnosis, ill health or other reasons.

“There are pluses and minuses, but a VAD can extend your life as long as a transplant,” Dr. Amos said. “So it’s a pretty good option.”

Patients don’t need to know all the specifics of heart failure treatments – they’re changing all the time anyway. The key is to act sooner than later, says Dr. Amos.

“There’s just so much we can do if we diagnose these patients early.”
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