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Hello everyone. My name is Jacob Emerson.

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I'm an editor with Becker's Healthcare.

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Thanks so much for tuning in to the
Becker's Healthcare podcast series.

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Today we're gonna be discussing advanced
heart failure and the C T V S A heart

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failure practice. We're thrilled today
to be joined by Dr. William Kotz and Dr.

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Christopher Shaana, both of you.

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Thank you so much for taking the
time to join us on the podcast today.

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Thank you, Jacob.

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Yeah, thank you.

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Well, with that, I'll turn it over to Dr.

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Kotz first for a brief description of
the C T V S A heart failure practice.

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Sure. We have seven heart failure
physicians in our C T V S A practice.

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We have a total of 12 physicians
who we work together at Advocate

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Christ Medical Center. And, uh,

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heart failure usually
includes a couple of things.

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It's the basic management and
prevention of heart failure,

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and often when it with regards
to advanced heart failure.

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So we take care of people who
have ventricular assist devices

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or heart transplants. So it's kind
of those three different things.

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Heart failure, LVA ds,
and heart transplantation.

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Fantastic. Well, I appreciate you
setting the floor there for us, Dr. Kotz.

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Let's jump right in then to some
questions for you both. Dr. Shaman,

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if you could start by just explaining
for us the role of what you do every day

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as an advanced heart failure cardiologist.

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What are the kind of patients
that you're treating?

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What's the scope of your practice and
how does that all kind of differ from

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other cardiology specialties?

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Yeah, it's a good question. Um, you
know, as Dr. Kot had mentioned, uh,

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part of what we do is we do take care
of patients that either are being

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evaluated for left ventricular
cyst devices or L vva ds. Um,

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we also take care of patients that are
being evaluated or have had a heart

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transplant. Um, but I, you know, we,

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we've all had specialized training
after our cardiology training and board

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certifications, uh, to be, um, you
know, to specialize in these fields.

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I think the other thing that's really
important that, that does differ us is,

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is that we do take care of
all types of cardiomyopathies

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as well as all different types of stages.

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So these patients don't necessarily need
to be on DeFoor and need a transplant

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today. Um,

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myself as well as a lot of our colleagues
have other expertise in taking care

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of patients that have heart failure
with preserved ejection fraction.

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We take care of infiltrative
cardiomyopathy, hypertrophic
cardiomyopathy,

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and um, as I mentioned, even
patients that maybe not,

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are not quite at the advanced
stage of heart failure. Um,

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cuz we really focus on the
intricacies of maybe the diagnosis,

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but also the management of all these
patients and if they do progress in their

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disease to getting them to that next
step such as heart transplant or L D a.

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I see.

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So you both have specialized training
beyond normal cardiology and you can serve

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patients who have had l vva DS or heart
transplants among other things. Dr.

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Kotz, um,

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I'm wondering if you could kind of zoom
out for us a little bit and give us the

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wider context on the scope and the
scale of heart failure in the us.

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Why are we talking about this today?
I mean, why is this such a big deal?

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It's a big deal for a couple of reasons.

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The two main reasons are it's very common.

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About 6.5 million Americans
have the diagnosis of

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heart failure and if left untreated,

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it can become very serious
and limit people's lives.

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And even if it doesn't do that,

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it can impair people's
quality of life more than, uh,

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$40 billion are also expended on, uh,

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heart failure a year in the us.
So it's obviously also a big cost,

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but we're actually obviously
more interested in people's
lives and it just has

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an tremendous effect on how people live.

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Wow. Six and a half million
Americans with heart failure.

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It's a very large number.

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So given that this is so prevalent and
obviously such a significant illness,

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how do you both think that we should be
diagnosing heart failure before people

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really get sick?

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Yeah, well, like any area of prevention,

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it's important to get there early
and important to assess people early.

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And so the,

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some of the cardiology societies
have recognized that over the

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last 10 to 15 years.

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What they've realized is
that there are a lot of key

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diseases, disease states
that lead to heart failure,

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high blood pressure,
hypertension, obesity.

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Perhaps someone received a
chemotherapeutic agent that
might affect the heart.

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Um, coronary artery disease.

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All these things can lead to
heart failure. So in a sense,

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these are conditions that some
people would consider very early

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heart failure. So if you have
anyone who has any of these issues,

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you can consider doing more of
an evaluation. Uh, first of all,

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treating those conditions
to prevent heart failure,

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but also perhaps looking for
heart failure in certain cases,

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like getting an echocardiogram or
something called an NTB and P test

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to look for whether that
patient may have heart failure.

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So when the right patients, there's a,

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there's a higher prevalence of
heart failure, you can look for it,

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evaluate and treat it.

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So if we're talking about
catching these issues earlier,

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are you finding that there's certain
medical problems that are more prone to

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lead to heart failure or other ways that
developing it can be avoided in terms

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of living your life? Um, or are there
medications that can prevent it?

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Yeah, so, um, take, take for example,

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coronary disease, one of the more
common cardiac problems in America.

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Um, there's way better
treatments over the last 20,

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30 years for treating that and evaluating
for it. You can get stress tests,

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you can do angiograms and
in terms of medications,

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absolutely in many of those patients,

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it's recommended that people get on
ACE inhibitors and beta blockers.

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And those medicines are also, it turns
out treatments for heart failure.

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So if you can treat these things
earlier and we see, you know,

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we see less of these heart attacks
resulting in heart failure than we

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used to, but we still see a lot of it.
Uh, for example, in high blood pressure,

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treating high blood pressure overlaps
with the treatments for heart failure as

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well. If you can get to that early losing
weight, there's something called, uh,

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metabolic syndrome with obese pat
patients with glucose intolerance

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where you want to, um, lose weight, uh,

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eat better exercise, and you can
prevent heart failure that way as well.

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Diabetes is another key risk factor
for heart failure in which there are

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medications for that. And
in some of these patients,

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a certain medicines that we
also treat for heart failure,

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you can take and prevent heart failure.

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So there's lots of different areas and
prevention is obviously the area where

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you can, you know, save the most
lives and decrease morbidity the most.

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Sure, absolutely.

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So plenty of ways to prevent this and
treatments it sounds like have improved

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over the last few decades.

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What about medications that are used to
treat heart failure once it's an issue?

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Yeah, once it's an issue,

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now there are four major
medic medications we recommend

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25, 30 years ago, there was one
new one that was ACE inhibitors.

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And so there are four major
groups now and those are, uh,

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ACE inhibitors or ARBs, angiotensin,

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angiotensin receptor
blockers, beta blockers, um,

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mineral mineral corticoid receptor
blockers like spironolactone.

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And uh, finally modifications
like, uh, I'm sorry, sgl,

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L T two inhibitors.

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And so those four different pillars are
what we try to get everybody on right

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now. And all of these medicines,

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every one of them can improve
survival in patients with

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decreased heart function.

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And in some cases they can
make the function better

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and, um,

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they can lead people to having
less symptoms and, and as I said,

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living longer.

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I see. So Dr. Shaana then, Dr.

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Kotz just mentioned there's four pillars
of medications recommended for the

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treatment of heart failure.

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Can you tell us a little bit about
your experience directly treating heart

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failure patients? Do these
medications work? Um,

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can all patients tolerate
all these medications?

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Yeah, I mean it's, it's an important,
it's an important discussion to have.

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Um, you know, we, the, the
patients sometimes ask us
if these medications work,

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other care providers may ask
us the same thing. I think my,

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my response to that is kind of a, a
very general statement is just to say,

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yes, these medications do work.
We have lots of very good, uh,

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data, uh, over the past
several decades, uh,

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well-designed trials at each of these
different pillars of medications show

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benefit to our patients.

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There's even some other medications
that may be used at times. Um,

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I think a lot of care providers are
very confident and pretty consistent

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on using some of the medications that
were showed early benefit back in the,

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you know, late eighties and nineties,

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even specifically the beta blockers
and the ACE inhibitors as Dr.

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Kotz had mentioned.

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But it's important to understand that
over the past several years we've had some

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new medications that have come out,

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such as the SGLT two inhibitors
and sacubitril valsartan,

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which is something that falls under
the class of angio angiotensin receptor

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neprilysin inhibitor. Um,
people ask us, you know,

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is it too much medication
to be giving these patients?

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I think what's important is I,

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I go back to the original data with
the beta blockers and ACE inhibitors,

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and we know those medications
have benefits, but importantly,

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these newer medications like SGLT two
inhibitors and Sacubitril Valsartan, um,

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those medications, they not only
showed benefit in the trials, uh,

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the heart failure trials,

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but they showed benefit on patients in
patients that were on background therapy

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with beta blockers and ACE
inhibitors. So ultimately, you know,

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each of these medications kind
of has an additive effect. The,

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the more of them we use, which then of
course goes to the question is, you know,

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you'd mentioned, well one, do
patients tolerate them? Um,

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we get questions about this, you know,

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sometimes the blood pressure can be
lowered with these medications. Um,

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my answer is, you know, believe it or not,

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sometimes if you just kind
of start really low doses and

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over time, uh,

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carefully go up on the doses and
monitor your patients closely,

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we can actually get people to
achieve high dose max tolerated,

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um, therapy of all these
different medications.

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Now that may take a
team approach, you know,

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if you have availability
to a heart failure clinic
that has nurses and advanced

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practitioners that are educated
on the side effects and how to

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um, uh, titrate and manage
some of these medications,

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that can be a big help to
get people on good therapy.

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But ultimately we should
continue to try to push them.

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And then the last thing is, you know,
are the patients gonna take 'em?

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It's a lot of medications,
it's a lot of changes,

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especially as we're up titrating
doses and of course nobody wants to

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take medications that doesn't make 'em
feel different, you know, immediately.

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I think the biggest thing is to, every
time we're seeing these patients,

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every time we, um,

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encounter them is educating
'em about the medication,

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the doses,

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but also specifically the importance
of why are we putting them on these

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medications because of these benefits.
As Dr. Kotz had mentioned to, you know,

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these are, these have been shown to
improve survival, reduce heart failure,

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hospitalizations, help people feel
better and maybe even recover their,

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their left ventricular
ejection for action.

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Yeah, and I appreciate you
making that point cuz it's a,

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it's a really good one that
these medications they work,

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but how do you convince patients to,
to take them at the end of the day?

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So now that you,

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you both have this depth of experience
caring for heart failure patients,

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are there any, um,

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important points that you wish that you
knew personally about patient management

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earlier in your career
or even in your training?

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Yeah, I think one of the things is
that, uh, kind of progresses in,

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in one's career that it's really
important to listen to the patient

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and know that all patients are coming
from a different place and there isn't

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always one right answer for treatment.

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And you have to sometimes
modify things depending on the,

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the specific individual. So I, I
think that's one thing, you know,

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I've certainly learned over time is
that listing the patient sometimes will

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have these very advanced
patients and not everybody wants

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these life-saving therapies when
they're very ill. Most people do.

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But I think having really
in-depth discussions with
these patients about these

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things to really understand what
they want after they're informed.

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Our job is really to inform people with
what we know about the data and, uh,

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survival, things like that.

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And let the patients and the
families are also very important

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in some of our more advanced heart
failure treatment options like transplant

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and mechanical assist devices.

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It's a great point. Um,

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I think we could probably go on for hours
about things that we've learned over

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the years. Um,

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I think some important things that
I learned early on is, you know,

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I think back to even my days in
residency training, you know,

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we all see patients, doesn't
matter what field you're in,

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we all see people that have heart failure.

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There's this tendency though to
think that it's an acute issue.

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And the reality is unfortunately is
even though people come in sick to the

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hospital, we give them medicine,

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we give them diuretics
to get fluid off of them,

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we make their breathing feel better,
we get their blood pressure better,

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they come and see us in the clinic.

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I think one thing that's important to
remember is that this really is a chronic

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disease and no matter how
good we can get them feeling,

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even if we can recover their,
their heart function, um,

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at some point in time the disease
is gonna progress. So not getting,

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don't feel complacent with
this disease that, you know,

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you pat yourself on the back cuz you
got someone out of the hospital and they

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look okay in the clinic.

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You have to just keep on watching them
because at some point that day will come,

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well, things will get worse. Um,
and and with that is, you know,

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I think going to Dr.

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Katz's point about talking to
your patients and families and

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sometimes what is is
really still, I think,

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humbling to this day is how
much really these really sick

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people can kind of fool you. You know,

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you can see people come into your clinic
and they look comfortable in a chair

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and they tell you maybe even
that they're feeling okay.

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And when you really dive into
it, you learn that, you know,

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they're not walking as far anymore and
they can't breathe as well when they do

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things and they're changing
their life to compensate for it.

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But recognizing some of these signs of
when someone's disease is progressing

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because the earlier we can recognize
somebody's advancing in their disease is

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the, the earlier we can get on board with
to see if they need things like heart

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transplant or l a s.

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Sure. And you know, Dr. Shani, you,

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you bring up a great point
that this disease is a
progression that starts before

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a patient sees a specialist like yourself.

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So how would you like other
physicians to refer their patients to

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advanced heart failure specialists
or when and and are there certain

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disease progression signals, um, that
that that they need an a H F referral?

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Yeah, another good question
too. Um, you know, we,

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we a lot of times get referrals
and stuff, uh, when it's,

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when it's obvious somebody's at
that advanced stage, you know,

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whether they see them in clinic or the
patient's stuck in the hospital. Um,

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but there's other things that we have
to kind of dive into. So, you know,

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first off, I guess to answer the
question, when do I wanna see a patient?

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My rule of thumb is just
I'll see 'em anytime.

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If you have a heart failure patient,
that's, even if they're relatively stable,

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uh, there's no such thing to
me as a too early referral,

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I'm always happy to see them.
I think Dr. Kotz is the same.

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To see them in clinic, you know, make
sure is is there anything else that,

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you know,

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we should look into any adjustments
to the therapies and you know,

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if, if their, their current
cardiologist or, you know, um,

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their primary care physician is
doing a good job, we say, Hey,

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you're doing a good job and maybe they
don't need to come back and see me right.

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Quite right right now. But, but
I think for the most part, um,

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things to really look for as
far as if you are concerned,

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someone's starting to kind of go down
that slippery slope and developing

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advanced heart failure. Um,
there's some nice little, you know,

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things out there. There's something called
the I need help, uh, which, you know,

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each letter is gonna stand for
something. For instance, you know,

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I is a patient that is on inotrope
medications like dobutamine or mill

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or known, uh, or if they've ever needed
to have them, they may not be on them.

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Now that's a concerning sign if
somebody needs those therapies. Um,

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assessing the New York Heart Association
classification, uh, if you know,

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despite your best efforts, your
patients still are N Y H A, you know,

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three s even, uh, three or four,

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those patients are probably pretty
sick ejection fractions, you know, 30,

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25%. Those patients are probably
pretty sick as well too,

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and would warrant a referral
to advanced heart failure.

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So it doesn't have to be an
ejection fraction of 10%. Um,

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we look at other things, um,
uh, the end organ function,

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you know, when we start to see the
other organs like the kidneys go bad,

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the liver goes bad. Those
are concerning signs.

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I think a big one that's overlooked
is I c d shocks for ventricular

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arrhythmias. Um, it's easy to kind of,

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somebody has a shock and we make
sure the electrolytes are okay and we

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send them on the way they look. Okay.

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But when somebody has especially a
reduced LV function and they're being

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shocked, that may be something that's a
sign that their disease is progressing.

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Um,

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one big one I think that's often
overlooked is recurrent heart failure

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hospitalizations. Um, so yeah,

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I think we've all seen the patients that
are always in the hospital every month.

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And really what we know and the data
shows us is that as people get sicker,

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it becomes harder for them
to stay out of the hospital.

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And that's a sentinel event
when somebody gets hospitalized.

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So we really have to take that seriously.

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And to kind of go back to some of the
pearls maybe that we talked about,

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one thing I used to do,

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I remember in in my residency is you'd
see somebody coming into the hospital

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00:19:19,670 --> 00:19:21,310
frequently and you,

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00:19:21,310 --> 00:19:25,350
you do a good job in history and you learn
that they ate some pizza or something

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00:19:25,350 --> 00:19:26,070
with, you know,

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00:19:26,070 --> 00:19:30,350
a lot of salt or fluid and you kind of
blame the patient like that's why they're

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00:19:30,350 --> 00:19:33,830
in the hospital. Um, it may
put 'em in the hospital,

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00:19:33,830 --> 00:19:37,350
but I think you really have
to be concerned that these
people are probably just

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00:19:37,350 --> 00:19:40,750
eating pizza every day and it's actually
their heart's just getting sicker.

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So heart failure hospitalizations
is something to be taken seriously.

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If we can't keep people,

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keep the fluid in the edema
off of patients is important,

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00:19:48,870 --> 00:19:53,190
blood pressure is starting to drop down
or they're not tolerating some of these

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good medical therapies
that they used to tolerate.

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00:19:55,320 --> 00:19:57,070
If you have to start
peeling back on those,

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that's a sign of somebody that's
advancing. So lots of different things.

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00:20:01,300 --> 00:20:03,870
I would, you know, recommend going to the,

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00:20:03,930 --> 00:20:07,750
the I need help acronym is helpful for
people to kind of remember some of that

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list.

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00:20:09,080 --> 00:20:13,760
Fantastic. Well, we've covered a lot of
ground and details today. So Dr. Kotz,

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Dr. Shaman, I want to thank you both
for your time and your insights today.

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Thank you. Yeah, thank you.

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00:20:20,460 --> 00:20:25,310
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