Hello everyone. My name is Jacob Emerson.
I'm an editor with Becker's Healthcare.
Thanks so much for tuning in to the Becker's Healthcare podcast series.
Today we're gonna be discussing advanced heart failure and the C T V S A heart
failure practice. We're thrilled today to be joined by Dr. William Kotz and Dr.
Christopher Shaana, both of you.
Thank you so much for taking the time to join us on the podcast today.
Thank you, Jacob.
Yeah, thank you.
Well, with that, I'll turn it over to Dr.
Kotz first for a brief description of the C T V S A heart failure practice.
Sure. We have seven heart failure physicians in our C T V S A practice.
We have a total of 12 physicians who we work together at Advocate
Christ Medical Center. And, uh,
heart failure usually includes a couple of things.
It's the basic management and prevention of heart failure,
and often when it with regards to advanced heart failure.
So we take care of people who have ventricular assist devices
or heart transplants. So it's kind of those three different things.
Heart failure, LVA ds, and heart transplantation.
Fantastic. Well, I appreciate you setting the floor there for us, Dr. Kotz.
Let's jump right in then to some questions for you both. Dr. Shaman,
if you could start by just explaining for us the role of what you do every day
as an advanced heart failure cardiologist.
What are the kind of patients that you're treating?
What's the scope of your practice and how does that all kind of differ from
other cardiology specialties?
Yeah, it's a good question. Um, you know, as Dr. Kot had mentioned, uh,
part of what we do is we do take care of patients that either are being
evaluated for left ventricular cyst devices or L vva ds. Um,
we also take care of patients that are being evaluated or have had a heart
transplant. Um, but I, you know, we,
we've all had specialized training after our cardiology training and board
certifications, uh, to be, um, you know, to specialize in these fields.
I think the other thing that's really important that, that does differ us is,
is that we do take care of all types of cardiomyopathies
as well as all different types of stages.
So these patients don't necessarily need to be on DeFoor and need a transplant
today. Um,
myself as well as a lot of our colleagues have other expertise in taking care
of patients that have heart failure with preserved ejection fraction.
We take care of infiltrative cardiomyopathy, hypertrophic cardiomyopathy,
and um, as I mentioned, even patients that maybe not,
are not quite at the advanced stage of heart failure. Um,
cuz we really focus on the intricacies of maybe the diagnosis,
but also the management of all these patients and if they do progress in their
disease to getting them to that next step such as heart transplant or L D a.
I see.
So you both have specialized training beyond normal cardiology and you can serve
patients who have had l vva DS or heart transplants among other things. Dr.
Kotz, um,
I'm wondering if you could kind of zoom out for us a little bit and give us the
wider context on the scope and the scale of heart failure in the us.
Why are we talking about this today? I mean, why is this such a big deal?
It's a big deal for a couple of reasons.
The two main reasons are it's very common.
About 6.5 million Americans have the diagnosis of
heart failure and if left untreated,
it can become very serious and limit people's lives.
And even if it doesn't do that,
it can impair people's quality of life more than, uh,
$40 billion are also expended on, uh,
heart failure a year in the us. So it's obviously also a big cost,
but we're actually obviously more interested in people's lives and it just has
an tremendous effect on how people live.
Wow. Six and a half million Americans with heart failure.
It's a very large number.
So given that this is so prevalent and obviously such a significant illness,
how do you both think that we should be diagnosing heart failure before people
really get sick?
Yeah, well, like any area of prevention,
it's important to get there early and important to assess people early.
And so the,
some of the cardiology societies have recognized that over the
last 10 to 15 years.
What they've realized is that there are a lot of key
diseases, disease states that lead to heart failure,
high blood pressure, hypertension, obesity.
Perhaps someone received a chemotherapeutic agent that might affect the heart.
Um, coronary artery disease.
All these things can lead to heart failure. So in a sense,
these are conditions that some people would consider very early
heart failure. So if you have anyone who has any of these issues,
you can consider doing more of an evaluation. Uh, first of all,
treating those conditions to prevent heart failure,
but also perhaps looking for heart failure in certain cases,
like getting an echocardiogram or something called an NTB and P test
to look for whether that patient may have heart failure.
So when the right patients, there's a,
there's a higher prevalence of heart failure, you can look for it,
evaluate and treat it.
So if we're talking about catching these issues earlier,
are you finding that there's certain medical problems that are more prone to
lead to heart failure or other ways that developing it can be avoided in terms
of living your life? Um, or are there medications that can prevent it?
Yeah, so, um, take, take for example,
coronary disease, one of the more common cardiac problems in America.
Um, there's way better treatments over the last 20,
30 years for treating that and evaluating for it. You can get stress tests,
you can do angiograms and in terms of medications,
absolutely in many of those patients,
it's recommended that people get on ACE inhibitors and beta blockers.
And those medicines are also, it turns out treatments for heart failure.
So if you can treat these things earlier and we see, you know,
we see less of these heart attacks resulting in heart failure than we
used to, but we still see a lot of it. Uh, for example, in high blood pressure,
treating high blood pressure overlaps with the treatments for heart failure as
well. If you can get to that early losing weight, there's something called, uh,
metabolic syndrome with obese pat patients with glucose intolerance
where you want to, um, lose weight, uh,
eat better exercise, and you can prevent heart failure that way as well.
Diabetes is another key risk factor for heart failure in which there are
medications for that. And in some of these patients,
a certain medicines that we also treat for heart failure,
you can take and prevent heart failure.
So there's lots of different areas and prevention is obviously the area where
you can, you know, save the most lives and decrease morbidity the most.
Sure, absolutely.
So plenty of ways to prevent this and treatments it sounds like have improved
over the last few decades.
What about medications that are used to treat heart failure once it's an issue?
Yeah, once it's an issue,
now there are four major medic medications we recommend
25, 30 years ago, there was one new one that was ACE inhibitors.
And so there are four major groups now and those are, uh,
ACE inhibitors or ARBs, angiotensin,
angiotensin receptor blockers, beta blockers, um,
mineral mineral corticoid receptor blockers like spironolactone.
And uh, finally modifications like, uh, I'm sorry, sgl,
L T two inhibitors.
And so those four different pillars are what we try to get everybody on right
now. And all of these medicines,
every one of them can improve survival in patients with
decreased heart function.
And in some cases they can make the function better
and, um,
they can lead people to having less symptoms and, and as I said,
living longer.
I see. So Dr. Shaana then, Dr.
Kotz just mentioned there's four pillars of medications recommended for the
treatment of heart failure.
Can you tell us a little bit about your experience directly treating heart
failure patients? Do these medications work? Um,
can all patients tolerate all these medications?
Yeah, I mean it's, it's an important, it's an important discussion to have.
Um, you know, we, the, the patients sometimes ask us if these medications work,
other care providers may ask us the same thing. I think my,
my response to that is kind of a, a very general statement is just to say,
yes, these medications do work. We have lots of very good, uh,
data, uh, over the past several decades, uh,
well-designed trials at each of these different pillars of medications show
benefit to our patients.
There's even some other medications that may be used at times. Um,
I think a lot of care providers are very confident and pretty consistent
on using some of the medications that were showed early benefit back in the,
you know, late eighties and nineties,
even specifically the beta blockers and the ACE inhibitors as Dr.
Kotz had mentioned.
But it's important to understand that over the past several years we've had some
new medications that have come out,
such as the SGLT two inhibitors and sacubitril valsartan,
which is something that falls under the class of angio angiotensin receptor
neprilysin inhibitor. Um, people ask us, you know,
is it too much medication to be giving these patients?
I think what's important is I,
I go back to the original data with the beta blockers and ACE inhibitors,
and we know those medications have benefits, but importantly,
these newer medications like SGLT two inhibitors and Sacubitril Valsartan, um,
those medications, they not only showed benefit in the trials, uh,
the heart failure trials,
but they showed benefit on patients in patients that were on background therapy
with beta blockers and ACE inhibitors. So ultimately, you know,
each of these medications kind of has an additive effect. The,
the more of them we use, which then of course goes to the question is, you know,
you'd mentioned, well one, do patients tolerate them? Um,
we get questions about this, you know,
sometimes the blood pressure can be lowered with these medications. Um,
my answer is, you know, believe it or not,
sometimes if you just kind of start really low doses and
over time, uh,
carefully go up on the doses and monitor your patients closely,
we can actually get people to achieve high dose max tolerated,
um, therapy of all these different medications.
Now that may take a team approach, you know,
if you have availability to a heart failure clinic that has nurses and advanced
practitioners that are educated on the side effects and how to
um, uh, titrate and manage some of these medications,
that can be a big help to get people on good therapy.
But ultimately we should continue to try to push them.
And then the last thing is, you know, are the patients gonna take 'em?
It's a lot of medications, it's a lot of changes,
especially as we're up titrating doses and of course nobody wants to
take medications that doesn't make 'em feel different, you know, immediately.
I think the biggest thing is to, every time we're seeing these patients,
every time we, um,
encounter them is educating 'em about the medication,
the doses,
but also specifically the importance of why are we putting them on these
medications because of these benefits. As Dr. Kotz had mentioned to, you know,
these are, these have been shown to improve survival, reduce heart failure,
hospitalizations, help people feel better and maybe even recover their,
their left ventricular ejection for action.
Yeah, and I appreciate you making that point cuz it's a,
it's a really good one that these medications they work,
but how do you convince patients to, to take them at the end of the day?
So now that you,
you both have this depth of experience caring for heart failure patients,
are there any, um,
important points that you wish that you knew personally about patient management
earlier in your career or even in your training?
Yeah, I think one of the things is that, uh, kind of progresses in,
in one's career that it's really important to listen to the patient
and know that all patients are coming from a different place and there isn't
always one right answer for treatment.
And you have to sometimes modify things depending on the,
the specific individual. So I, I think that's one thing, you know,
I've certainly learned over time is that listing the patient sometimes will
have these very advanced patients and not everybody wants
these life-saving therapies when they're very ill. Most people do.
But I think having really in-depth discussions with these patients about these
things to really understand what they want after they're informed.
Our job is really to inform people with what we know about the data and, uh,
survival, things like that.
And let the patients and the families are also very important
in some of our more advanced heart failure treatment options like transplant
and mechanical assist devices.
It's a great point. Um,
I think we could probably go on for hours about things that we've learned over
the years. Um,
I think some important things that I learned early on is, you know,
I think back to even my days in residency training, you know,
we all see patients, doesn't matter what field you're in,
we all see people that have heart failure.
There's this tendency though to think that it's an acute issue.
And the reality is unfortunately is even though people come in sick to the
hospital, we give them medicine,
we give them diuretics to get fluid off of them,
we make their breathing feel better, we get their blood pressure better,
they come and see us in the clinic.
I think one thing that's important to remember is that this really is a chronic
disease and no matter how good we can get them feeling,
even if we can recover their, their heart function, um,
at some point in time the disease is gonna progress. So not getting,
don't feel complacent with this disease that, you know,
you pat yourself on the back cuz you got someone out of the hospital and they
look okay in the clinic.
You have to just keep on watching them because at some point that day will come,
well, things will get worse. Um, and and with that is, you know,
I think going to Dr.
Katz's point about talking to your patients and families and
sometimes what is is really still, I think,
humbling to this day is how much really these really sick
people can kind of fool you. You know,
you can see people come into your clinic and they look comfortable in a chair
and they tell you maybe even that they're feeling okay.
And when you really dive into it, you learn that, you know,
they're not walking as far anymore and they can't breathe as well when they do
things and they're changing their life to compensate for it.
But recognizing some of these signs of when someone's disease is progressing
because the earlier we can recognize somebody's advancing in their disease is
the, the earlier we can get on board with to see if they need things like heart
transplant or l a s.
Sure. And you know, Dr. Shani, you,
you bring up a great point that this disease is a progression that starts before
a patient sees a specialist like yourself.
So how would you like other physicians to refer their patients to
advanced heart failure specialists or when and and are there certain
disease progression signals, um, that that that they need an a H F referral?
Yeah, another good question too. Um, you know, we,
we a lot of times get referrals and stuff, uh, when it's,
when it's obvious somebody's at that advanced stage, you know,
whether they see them in clinic or the patient's stuck in the hospital. Um,
but there's other things that we have to kind of dive into. So, you know,
first off, I guess to answer the question, when do I wanna see a patient?
My rule of thumb is just I'll see 'em anytime.
If you have a heart failure patient, that's, even if they're relatively stable,
uh, there's no such thing to me as a too early referral,
I'm always happy to see them. I think Dr. Kotz is the same.
To see them in clinic, you know, make sure is is there anything else that,
you know,
we should look into any adjustments to the therapies and you know,
if, if their, their current cardiologist or, you know, um,
their primary care physician is doing a good job, we say, Hey,
you're doing a good job and maybe they don't need to come back and see me right.
Quite right right now. But, but I think for the most part, um,
things to really look for as far as if you are concerned,
someone's starting to kind of go down that slippery slope and developing
advanced heart failure. Um, there's some nice little, you know,
things out there. There's something called the I need help, uh, which, you know,
each letter is gonna stand for something. For instance, you know,
I is a patient that is on inotrope medications like dobutamine or mill
or known, uh, or if they've ever needed to have them, they may not be on them.
Now that's a concerning sign if somebody needs those therapies. Um,
assessing the New York Heart Association classification, uh, if you know,
despite your best efforts, your patients still are N Y H A, you know,
three s even, uh, three or four,
those patients are probably pretty sick ejection fractions, you know, 30,
25%. Those patients are probably pretty sick as well too,
and would warrant a referral to advanced heart failure.
So it doesn't have to be an ejection fraction of 10%. Um,
we look at other things, um, uh, the end organ function,
you know, when we start to see the other organs like the kidneys go bad,
the liver goes bad. Those are concerning signs.
I think a big one that's overlooked is I c d shocks for ventricular
arrhythmias. Um, it's easy to kind of,
somebody has a shock and we make sure the electrolytes are okay and we
send them on the way they look. Okay.
But when somebody has especially a reduced LV function and they're being
shocked, that may be something that's a sign that their disease is progressing.
Um,
one big one I think that's often overlooked is recurrent heart failure
hospitalizations. Um, so yeah,
I think we've all seen the patients that are always in the hospital every month.
And really what we know and the data shows us is that as people get sicker,
it becomes harder for them to stay out of the hospital.
And that's a sentinel event when somebody gets hospitalized.
So we really have to take that seriously.
And to kind of go back to some of the pearls maybe that we talked about,
one thing I used to do,
I remember in in my residency is you'd see somebody coming into the hospital
frequently and you,
you do a good job in history and you learn that they ate some pizza or something
with, you know,
a lot of salt or fluid and you kind of blame the patient like that's why they're
in the hospital. Um, it may put 'em in the hospital,
but I think you really have to be concerned that these people are probably just
eating pizza every day and it's actually their heart's just getting sicker.
So heart failure hospitalizations is something to be taken seriously.
If we can't keep people,
keep the fluid in the edema off of patients is important,
blood pressure is starting to drop down or they're not tolerating some of these
good medical therapies that they used to tolerate.
If you have to start peeling back on those,
that's a sign of somebody that's advancing. So lots of different things.
I would, you know, recommend going to the,
the I need help acronym is helpful for people to kind of remember some of that
list.
Fantastic. Well, we've covered a lot of ground and details today. So Dr. Kotz,
Dr. Shaman, I want to thank you both for your time and your insights today.
Thank you. Yeah, thank you.
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