Matters of the Heart: Symptoms and Risk Factors

[MUSIC PLAYING] Welcome, everyone, to this roundtable discussion on heart failure. I'm John Whyte, the chief medical officer at WebMD. Six million Americans have heart failure. It's one of the most common reasons people are admitted to the hospital.

To help unpack it all, I'm joined by two experts. Dr. Reginald Robinson is a cardiologist at MedStar Health. And he's the president of the Board of the Directors for the Eastern States region of the American Heart Association. And Dr. Abiodun Ishola; he's an interventional cardiologist at St. Elizabeth Healthcare. Doctors, thanks for joining me.

Thanks for having us.

Thanks for having us.

Dr. Robinson, let's start off and level it for everyone, and help define what is heart failure. And how is that different than a heart attack? People often confuse those, so walk us through it.

They do, and that's sort of a moving target. When you think about heart failure, sometimes it's not in the setting where the heart has actually failed. The stages of heart failure-- we can talk about that a little later, but when the heart's not keeping up with the body needs. So you can have heart failure where your body's retaining a lot of fluid from a normal-functioning heart that's stiff. Or you can have heart failure from a heart that's enlarged. And there are multiple reasons for that, which we'll get into later.

But the symptoms complex are generally the same. Shortness of breath, you may have swelling, or what we call edema, in the legs. You may have fluid in the lungs that gives you that episode of shortness of breath, making it difficult for you to lay down flat, because you feel like you're being suffocated. So basically, it's your body's heart not being able to keep up with your actual needs.

But then how do patients distinguish it? Am I having a heart attack? Am I having heart failure? Why is that distinction important?

REGINALD ROBINSON: So with a heart attack, it could be a cause of heart failure. So when you think about a heart a attack, generally, the symptoms are chest pain, tightness, heaviness. In women, it may be just shortness of breath, especially with exertion. Sometimes it gets better when you stop exerting yourself. So a heart attack can be a cause of heart failure.

And then Dr. Ishola, what are the different stages?

So for heart failure, there are four major stages. And the first stage, just like any major disease process, is where you're asymptomatic, but you have significant risk factors. So that is what we term stage one. Stage two is, you're starting to have symptoms, but usually very mild symptoms. And a lot of times you can still perform a decent amount of activity, but with some amount of limitations.

When you get to the next stage, which is stage three, you're basically dealing with significant limitation in your functional status, or what we call your routine activity. Now it becomes very clear to everyone there are major limiting factors affecting your day-to-day function. And obviously, stage four has a detrimental point where you're basically symptomatic at rest.

You mentioned risk factors. What are those risk factors for heart failure?

REGINALD ROBINSON: So a major risk factor for heart failure-- to really get into that detail, first we have to talk about the major issues we see in heart failure. The number one cause of heart failure is coronary disease, that we know about. So we'll find out, like Dr. Robinson alluded to earlier, heart disease-- when it comes to coronary disease, there's a major reason for heart attack. That's why people develop heart failure.

And that being said, it makes sense because when the heart doesn't get enough blood flow, it can't function like it should, which leads to a gradual decline in the muscle function. The other risk factors -- high blood pressure and diabetes. Of course, we have to talk about the lifestyle issue. But I would say the top two that comes to mind, obviously, one is coronary disease, which is thickening and blockages in the blood vessels, and two is high blood pressure.

And then, Dr. Robinson, what are the current treatment options available?

So there are multiple treatment options. So if you're looking at something that's caused by a heart attack, one of the treatments in the field that Dr. Ishola is serving in is interventional cardiology, where you actually open up the artery to allow blood flow to go back to the heart.

When you think about hypertension, that's actually one of the leading causes of congestive heart failure. So treating your blood pressure to goal, not just kicking the can down the road. I can't tell you how often I see a patient that comes over and they say, well my blood pressure is 140 over 90. My doctor said it's good for me. It's like, no, it's not.

If your diabetes is out of control, that's considered a cardiovascular risk equivalent. If you have diabetes, you have heart disease until proven otherwise. So you should treat diabetes as aggressively as someone who has known heart disease, treating cholesterol, treating secondary causes of congestive heart failure, like if your thyroid is out of control, if you have an overactive thyroid, an underactive thyroid. So you have to look at the whole person and try to find out what's the most common cause, like coronary disease or hypertension, and treat those. If those aren't the main issues, then you try to look for the zebras and treat those.

So we're talking about treating the underlying causes-- hypertension, diabetes. I also want to hear about, what are the advances that we've made? How do we currently treat those patients who come in with CHF? I'm old. When I started training, it was primarily diuretics, certain hypertensive medications. But we've come a long way since then. So where exactly are we in terms of, what are the current treatment options that we have available to patients?

Absolutely. So some baseline things we know are beta blockers. That's definitely a go-to. You have your medications like metoprolol and Coreg. Those are the standard things. Then we have the ACE and ARBs, the lisonopril and losartans. Basically, now, there's Entresto, which is a combination of a neprilysin inhibitor and an ARB. So that is the go-to now for a lot of people with heart failure with normal renal function. You still have the old medications like Aldactone.

So I think all of that put together-- there's a lot of newer medications in the pipework that focuses on the NO pathway, and vasodilation as well. But for right now, the goal of treatment is trying to improve the heart function with beta blockers, either ACE or ARNI. We also know about some of the diabetic medications that have now been shown to improve outcomes in heart failure patients. So we have a lot of medication in the toolbox. For now, the average heart failure patient can have access to five, six medications. And of course, you always have the diuretics. That's still a go-to when it comes to symptomatic improvement.

Doctors, I want to thank you both for helping us to think through what are the strategies and solutions in the treatment of heart failure.

Thank you.

Thank you for having us.

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