Amin Yehya, MD, presents on the epidemiology of heart failure, when patients should be referred for further evaluation and discusses the different types of advanced heart failure therapies and outcomes.
Good morning, everybody. I'm Doctor. I mean, uh, medical physician for the that program here. Thank you for joining us today. 2021 vs Grand Rounds. Hope you guys enjoy it. Um, we're gonna be talking today with my colleague Dr Clinton Camp from surgery here at Xanterra Heart Hospital. He's also the lead and surgically for the bad M. C s program Thio. So we're gonna be talking about the candidates for D T therapy. And who are the patients with advanced heart failure and how to identify them? Um, disclosures, as you can see, have, um, Xia Car Jackson's all and my objectives of my part gonna be talking about the epidemiology of heart failure for the patients with advanced heart failure and how to identify them appropriately. Eso heart fair has been a long time and known since the days of Hippocrates. And he described the patients with heart failure than he called. The patient's appears yellow. The whole body, that dramatist, the face is red and mouth is dry, his thirsty and when he eats respiration, Quicken in the same day as sometimes may appear better while at others he's suffering acutely and seems on the verge of dying, and we see many patients special encourage enic shop patients or patients with acute, pretty concentrated heart failure who have similar picture. And Eugene Brown was one of the luminaries of cardiology described heart failure as the most frequent common pathway to death or serious disability in cardiovascular diseases that might be considered to be the price space for successful early mentions of these disorders. And it's true fact. In the past. For example, congenital heart disease patients used to live 20 years. Oh, that's more, especially those who congenital malformation that are complex but now with the advance off like multiple surgical techniques and intervention and marketing, is interventional procedures. These patients living longer and longer, similar things. Patients had my culture and functions in the past. They used to wait on them so they're in part, can complete. And if they made it through the night, then it's good. Now again, as we all know, there's sense, complex inventions and bypass surgeries, and these patients are living longer and longer. So how's heart failure doing? And I keep updating the slide frequently, um, especially with increased numbers of patients with heart failure currently around 6.2 million adults with heart failure, and this number is projected to continue to increase around eight million plus by year 2030. And Harter is the primary cause off death 5000 patients a year and contributing to one in every nine death. In 2018, it was mentioned around 13% of all that certificates. And if you want out yet, all patients with heart fair, those with significantly advanced disease and patients with, um, you know, early onset and you know uh huh currently compensated. The five year survival with patients with heart failure is around 50% and again it's the whole the median survival times. So after being diagnosed, patients have approximately 50% of station will make it to five years. Um, but what about patients with advanced heart failure patients who are on an entropic support? And I always use the slide just thio reemphasize the importance and the gravity of the disease. Patients with advanced heart failure who are on an entropic support have significantly high mortality rate, and they have, you know, Onley pancreatic cancer can pop them in, um, mortality. Basically around 25% of patients can lift one year we arrived or two in advance heart failure. So this is just important to keep in mind. In the past, AIDS was a big scare for everybody, or leukemia or lung cancer. But as you can see, the mortality rate at one year is significantly higher. And entrance, heart failure and advanced heart failure or heart for in general is not just a deadly disease is also a pretty coffee disease. And the cost of heart failure, especially um in the United States continues to go higher and higher every year, $2030 billion and now expect just off $70 billion in 2030. And most of this money spent on hospitalization fees, reimbursement care for patients and facilities and medications as well. So I would like to get you concentrate on the slide because it s so important. The sense that talks about the progression off heart failure since it get since the patient get diagnosed. Um, whenever the patient gets diagnosed, you can see quality of life on top half and the lower half of intensity of care. When the patients get diagnosed with heart failure, um, the quality of flight drops and then at that time you start. These patients in beta blocker is arbor Arnie and Maria is burning black tones. Patients do well for a period of time, and then at that time you see them in clinic and try Thio. Go up on their does is, But then they're going to be a period of time when these patients start to decompensate again. You might increase the dose to get ad more medications. But they're going to be a period of time when the patient starts to get hospitalized frequently when they start pulling medicine. All these patients, because they can't tolerate them. And this is the sweet spot and where I want you guys to focus because these stations are patients who can benefit from being referred for advanced heart failure Center. Um, there's an algorithm that has been used, um, frequently. That can help providers out in the community, especially primary care physicians or general cardiologists. And this is very basically friendly. You and you need to remember it's called. It's called I need Help, and this is what use also a interior on. We'll give it out when you go to do outreach events. Um I need help is basically I sense for patients from China tropes, and we're going to go over the data on that And basically, as you can see, New York Conversation three D and four d having an organ dysfunction. Another e is having ejection fraction less than 35% and d having I c d shocks. Um, For the health part, patients have more than one hospitalization e Adina, requiring aesthetic diuretic l having hypertension or elevated heart rate and P basically intolerance off or done Taxation of guideline direct medical therapy. So what is the data on IA tropes and, um, patients on IA trips? Um, and multiple study replicated that including, you know, uh, multiple trials have shown that patients who are maintained and I a tropes have significantly reduce one year survival and, you know, mortality rate as you can see her significantly high. Um, and that's why when you put patients on Miller known, we should have that in the back of our mind. Is this Miller known or do beauty meat or in a trope, as a bridge to transplant as a bridge for a That is a bridge Decision West Policy therapy because these medications, you might take you a little bit, feel better and can bridge you through a period of time. But there are toxic medicines themselves because they're pro arrhythmic, uh, medications. So you just have to be very judicial and using them and having a plan for patients when you put them on. So having a patient on a trip that you can see is associated with significantly reduced survival. The other thing is, as we mentioned, the New York Heart Association Class four or three B, which is patients are significantly limited by their heart failure. Um, they get short of breath just with minimal activity or exertions. The data from U A B by Vera Bittner and she showed that patients this is a long time data but replicated about on 93. Picture the patients with not able to walk more than 300 m and through the six minute walk in six minutes period of time. These patients have significantly reduced survival as well. These patients have a higher risk of hospitalizations you can see, and also they have worked quality of life for level one. Basically here as you can see, the patients who have who walked less than 300 m and more saturated, significantly higher higher hospitalization rate. And also they're usually class two or class for heart failure patients. One other thing. Also, we can we use, um, to further risk 25 patients. Is that cardiopulmonary exercise testing? What we can check the Max Vo two and docks in consumption? The lower it is. It's another indication of the lower cardiac output, and it's studies have shown patients have lower, uh, speak zero to less than 14. These patients would benefit more from product transplantation or advanced surgical options, one compared to medical therapies. We have a interior here. Howard Carter to Marie Mayer exercise testing. But we haven't started it again because of the covert times. And we're in the process potentially when things calm down, when Kobe is more control to restart it again. Another thing is, uh, is an organ dysfunction and, um, one of them most affected organs by heart failure is the kidneys because, you know, we just flush out, take in and do with sometimes with the progression of disease when you have, um, basically direct resistance organizations have this card arino syndrome when you have when there is worsening off the kidney function there is that multiple studies have shown that the survival is significantly affected. One of the best indicator is not just creating is actually is a rise in the the U. N. And the higher the U. N or the change in the B u N the worst survival. As you can see here in this, um, chart, the ejection fraction here on this side and the GF are the lower G f r with the lower ejection fraction as the highest, um, risk or worse outcome. So, um, you know, the kidneys are significantly, you know, is very important, and they are a good prognostic indicator of how the patient is really doing other and organs. Function is also the hyper Katrina. Um, serum sodium has been good. Indicator off how the disease has progressed. Patients with hyphenates premium multiple trials, including Dr Time and Escape trials, have shown that when the sodium levels listen 1 35 these stations test significant reduced survival and also have a higher risk of hospitalization. Even after you correct for this sodium happening premium by giving them medications, the survival rate is significantly low. There's no difference in survival. Um, there's risk. There's reduction hospital hospital sign. But there's no difference in survival only correct or hyponatremia. And that's how it's not just about correction of the sodium. It's about, um, the heart failure that have caused, um, that disease to progress to that. This is again remember that I need help. I n e on organs function. And the other end is that will be solid dysfunction. Um, definitely. We care about infraction because, as you can see her in this figure, um, the lower the ejection fraction the wars of survival independent if the patients are symptomatic or not. But when the patients become symptomatic, you can see here with LV dysfunction with heart failure, thes patients have worse survival rates. Andi, this is an echocardiogram off one of, um, my patients, basically, as you can see here, um, pictures till. But even though the picture until it does well, the ejection fraction and music conceded early is contracting. That'll be it's dilated on, um, significant reduced. And this is just another thought. She might digress a little bit. For example, patients who come into the hospital with ejection fraction of 10 15%. Getting an act on these patients if they had an acronym month or two or three or four or five is not significantly helpful. Not just to be flick to get an anchor, because again, what? He expected that Yes, it's 10 or 15 if they're coming in with the compensation. If even if it's a little bit like nine, whereas versus than 10, it won't change in the management. Just be very judicious in ordering echoes, especially when patients have reasoned echocardiograms. D. I need the deep part, which is getting defibrillation, or I see the therapies. Um um, studies independent patients getting therapies if it, um they're appropriate or inappropriate. Basically, um, thes patients have higher risk for worst outcome and death. As you can see here, Um, when the shock is, the higher the number of shocks, the wars of survival as well. And you know when patients coming in I cities shocking them. They're having V tech sometimes, especially if they're dilated and significant reduced ejection fraction and had hospitalization before VT ablation can put a small potentially band aid. But for these patients who come infrequently, we just have to think of the broader and the bigger pictures that their heart is screaming. And there in the end stage, um, period. So it might need further look into evaluation for advanced surgical options. Um, also, we have frequent flyers here. Has any institution patients who coming in frequency the hospital to get admitted to this hospital, go to other hospitals that other hospitals thio? Um, the more the patients get hospitalized, the worst of survival and when the risk stratified them and based upon the chronic kidney disease versus age, the worst that kidney function is the worst Survival. As you can see here, the hospitalization, um is and you can see here, for example, of CKD. I have patients four hospitalization or chronic function. The median survival is significant reduce. And also, as we get older, I will risk for everything goes up, especially also with heart failure. Keep an eye. One patient coming infrequently for hospitalization. Um, it's that prognostic sign diuretics Thio when we tried to escalate and go up on diuretics when patients are on higher than 80 off yours and mine, or to be me tonight and you know and you start going up in escalating a diuretic to get the response. And then that's what I mentioned before about having diabetic resistance. It means that the patients have becoming more resists, and their heart failure is significant as well. So multiple styles section that with increasing diuretic dosages can the patient requiring escalation of diuretics. It is a poor prognostic sign, and it's a sign that the patients have advanced to at advanced cardiomyopathy. Also, when you start taking medication off the patient and, um, it's a bad sign as well, when they're part when their blood pressures dropped when they become hypo tested, or when the kidney function worsened one of those medications long time ago into, UM, same long time 17 years ago in 2000 and three when they looked at MGH, I think that the patients who were discharged from the hospital patients who are discharged off case inhibitors at that time, these patients have significantly lower survival rate compared to patients who were discharged in AIDS inhibitors and when they compared even those who were discharged off because of hypertension, hyper Kalina or basically kidney dysfunction. And I trust these patients on our troops. Their survival rate in four months was significantly low again. We're talking about patients who were discharged from the hospital. And now we're using, like Arnie or ARB or ACE. Can we take starting these medicines out on the patients? Just another indicator off prognostic sign. Um, just for the curiosity of the all out there, um, you know, there are multiple risk scores and models out there and the key that we use that we can risk five patients based upon them. One of them is, um, the heart fares, um, score. And also a bit of Seattle heart fair model. Um so thes are for outpatients and for inpatient hospitalizations who have the escape and here in other models as well. So what to do with these patients when you identify the patients who they need help with the need treatment by advanced heart failure? A tous time. You're further Thio the center, which we're gonna talk about any few everybody thinks okay, perfect to get them transplanted. And, you know, because heart transplants, according is like the best treatment option for patients. But as you can see here that transplants numbers only the past two years have just one atop the world It's on 3400 heart transplants here. But again, as we're gonna see, there's around on where there's a lot of patients who might need these therapies. And not everybody is also a candidate for heart transplants. So the transplant survival is around. 13% of patients live the first year in Latin the past year or two. These numbers might change because of the recent transplant allocation changes, but again, the transplant survival is significantly higher. But again, we're taking one problem. Giving another issue. Tube is replacing patients, and I need on, you know, suppressant medications through procedures, stuff, infection, risk of rejection. But again, it is for some patients, definitely more appealing. Um, but what about who said there's around, um, X number of patients who have heart failure and, you know, talk about preserved and reduce ejection fraction here. They're around 60,000 patients in the states that might benefit from advanced surgical options and out of these patients. Basically, if we do only, let's say, 4000 heart transplant patients what they have 58,000 patients and we do around £5000 a year, totally total in the states. So there's a lot of patients out there that might benefit from further treatment options. Such left and progressive device. What you're gonna be talking about with my colleague here, So just keep in mind, um, when you see those signs off, I need help. I think patients online tropes, ejection fraction significantly reduced. Multiple hospitalization. I C D. Discharges having kidney dysfunctions, requiring I instructed to mention their sodium level of low. I see. Um, all these are bad prognostic signs.