Chapters Transcript Video What to Do When Medicines Stop Working Click here to view presentation deck Back to Symposium For those who don't know me, I'm a Miia here. I'm a heart cardiologist at CTERA and just a uh plug in for those uh in the primary care uh arena. I just wanna say that hopefully by 2026 we're gonna be starting our cardiology fellowship program at CTERA. So, um that will be a big thing for the community because we're gonna try to grow our own and help shape the future of cardiology by training them here at CTERA. So, uh I'm uh honored to be leading this initiative. Uh I just wanna say out there that we're gonna have a cardiology uh program. So, um moving on. So, um these are my disclosures. Um What are we gonna talk to you about when medication do not work? Uh Basically, um Let me see. I gave probably the wrong talk. Um I can I give you the, there is a different talk. I mean, can I uh a V guy in the back? Can I give you my uh talk? Uh probably and my laptop meanwhile, catch it. Meanwhile, I'm gonna say something I got this. Um So, one of the things that Kristen mentioned about uh GDMT. Um most of the time we tend to uh prescribe uh Arne or ARB. And whenever we see a rise in creatinine, this is something expected. So that should not preclude us from prescribing the medication. Basically, it's a one of the expected increase in creatinine. Uh So if somebody creatinine went up from 2 to 2.2 or something or 1 to 1.2 that should be totally fine. The second thing uh she mentioned about is that when we're prescribing Mras, um or if somebody has hyperkalemia and we try to take them off their uh Mras exer lactone or Urin, that should not be the case because now we're having medications that are class two B which are including like glaucoma or VTE, which are uh medications now are um, helping us keep these patients on GDMT because what's the worst thing for patients to happen to them is taking them off medications that can improve their survival and quality of life. And uh these medications include Arne, which is mainly Intreo and Mr A spiral lactone or Ali no beta blockers and SG al two inhibitors be dako or spironolactone. Uh So moving on without the talk is that, you know, despite having uh heart failure for a long time and we're having all these medications, the mortality from heart disease despite being on the four pills of GDMT continues to increase and that is could be from multiple reasons. Could be we are not giving the patient the adequate dosage of the medications. And if there was a study that recently came out, and it showed that we are not doing good job in putting these patients on the four pillars of GDMT primary care physicians. You guys out there in the community manage around 60 to 70% of all the heart failure out in the community. And it's important to empower you guys to uh basically manage these patients, be comfortable, prescribing our knees, uh interest or diag flows in or uh agy flows in because again, uh these medications have shown to improve survival and quality of life. So um heart failure, as you here, we can see here that that's from heart failure, it continued to increase with time. As you can see here in 2023 2021 the rise in mortality is going up. And that's despite the four pillars of GDMT and with age and men usually die more than women uh from heart failure when they compare to it. And this is the trend in hospitalization. We see it's, you know, usually you can see there's around 760,000 hospitalizations. Most of the patients hospitalized with heart failure are men and the comorbidities. And as you see mainly in your clinics, patients with sleep apnea, hypertension, obesity, smoking, all of these contribute basically to the overall uh deaths from the heart disease. Because again, when you see your patients out there, they have all these different comorbidities. And as we're gonna see in this, one of the figures to you later on, patients from heart failure and preserve ef which is around 50% of all outpatient heart failure, we see have these comorbidities and most of these patients die not just from heart disease, but because of lung disease and kidney failure. So it's important to treat these patients. And this is the annual hospitalization rate for heart failure. And again, despite the medications, we continue to see a rise in heart fail hospitalization. And this is this data just came out in the journal of cardiac failure. It's published in the last two weeks. Sorry, I gave this talk to different primary care group but uh I can share it with you too. So uh again, the trend in hospitalization continue to go up despite being on the four pillars of GDMT and the main cause of hospitalization for heart failure is patients coming into the emergency room saying I can't breathe and shortness of breath and symptoms are the main driving force. As Lauren mentioned, our shortness of breath brings people to the er and when patients come to the emergency room, 90% of patients who come into the er complaining of shortness of breath gonna be admitted, irrespective of what it is, even though they can give them a shot of IV Lasix or not. So um we're going back to our regular programming here. So thank you for saving the day. So going back to uh what you're gonna talk about, but again, it's important to try to treat and prevent this shortness of breath when they come to you. And now I think we live in a day and time where we can provide therapies for patients that can prevent that from happening. I mean, there is a subcutaneous Lasix injection who would even think about it. So patients can now administer themselves fosi which is a subcutaneous injection in their stomach, which is equivalent to the IV Lasix. And that can help prevent them from being hospitalized. So um can we advance, please? Ok, perfect. Again. So we're gonna move on from definition again, heart rate is getting more, we're diagnosing it more and this is also published two weeks ago, the numbers continue to go up and most of the time people think about heart failure um as something that don't have the significance. But if you look at it, people die from heart failure more than they die from cancer. And I use this slide frequently in most of my talk is that patients with end stage heart failure, they die more like than any type of lung cancer or leukemia or A I DS. Pancreatic cancer has higher mortality than patients with end stage heart failure. And again, it's not a just a deadly disease but a costly disease as well. And these are the treatment uh for patients with stages of heart failure. CND. And I think Lauren and Chris did a good job basically talking about the different uh guideline directed medical therapy. And this is straight from the guidelines, again, the four pillars and we get an I CD if they don't, you have does not recur uh recover. And again, for patients who do not get better with time and you can see later there's a transplant or an LVE or hospice. But one thing I wanna touch upon, I kinda like a little bit talked about. And I think somebody in that table mentioned about Pua uh which is the polys uh poly unsaturated fatty acids in the prior talk as well too. It is actually classed to be indications for patients with heart failure because it has shown to reduce mortality and cardiovascular hospitalizations. Also, I wanna talk about a little bit um glaucoma and valta and also these um therapies that reduces the hyperkalemia because again, these therapies are probably did not show themselves improving survival, but they can make sure that you are on therapies that can prevent you from dying from heart disease. So it's important to consider them and we can talk, I'm happy to talk to you outside or later on about the therapies as well. So again, if somebody's potassium go up on a spinal lactone or a pleon or in interests to do not stop this medication at the, you know, think about adding uh potassium lowering uh drugs to help keep your patients on them. So again, so this is one slide I wanna show is that despite guideline directed medical therapy, the overall two year mortality from heart failure, patient decompensated from heart failure is 9.1% despite being on the four pillars. And that's the residual risk basically. And as I mentioned too, is that how well are we doing? Not too well? Actually, if you look at this also published recently two weeks ago at J uh JCF, we are around like in the trials, we only like 73% of patients on ace RB or AR E and you know, 75% on the beta blocker or 58% on MRAS. So not many patients are on their GDMT. So we are not doing good job in getting our patients optimized on the therapies for heart failure if because and that as I if you remember, I showed this slide before where the mortality is going up despite the therapies again, are we providing our patients with the therapies for heart disease? So again, this is the mortality we showed it before and we talked about the hospitalization rate and despite all therapies, the hospitalization rate continues to go high with time. Again, it could be for multiple reasons, we can discuss it later on. But um I wanna talk a little bit about a case that will move us to what I'm talking about. 72 year old guy, non ischemic cardiomyopathy, that is no blockage causing him to have heart failure. He had been hospitalized three times, had I CD shot, he was on a little bit of carvedilol and A B A high dose. And his exam showed that he was hypertensive um his hypothermic fluid overloaded. So this is an echocardiogram. Basically, this is a, an image, his heart is barely moving as you can see here. Um So the ventricle is not contracting well and this is a sign of the heart is in that situation. So this is what we need to know about. The lo the more you get hospitalized from heart failure, the more your mortality rate or your death from heart disease goes up. As you can see here on the right panel, the higher the hospitalization rate, the mortality rate, the median survival goes down. Also the fraction, I mean sometimes we are hung up on the ef the lower the ejection fraction, the less the survival is. So his ef was like 10% generals uh 10% and this he was hospitalized three times. So that's by over all by itself is a poor indication. And this is a uh also from the recent publication which showing that patients would have with heart failure, their survival rate goes down with hospitalization independent of your race gender. But again, they found that patients who are black um in red as you can see here um they have higher mortality rate compared to others. And what I talked to you out in the community so sorry, I'm rushing but I'll try to be respectful of your time. Is that hospitalization rate or hospitalization event is a sentinel event to me. I look at it in different perspective because every time somebody gets hospitalized for heart failure, their survival rate goes down significantly. They say after one hospitalization, the five year survival from heart failure is at 25% 25% of patients will be alive in five years if they get hospitalized from heart failure. So heart fail is pretty serious. Sometimes we don't take it seriously enough. But again, we need to try to keep the patients at home and prevent their hospitalization. So again, the other thing is function capacity and that's why I ask patients how they're doing and like what they're doing in their life, the more the cap like, you know, they are limited from their disease. They're not walking much, you get short of breath doing anything um or their exercise capacity goes down, their survival rate goes pretty low. Also, we said we talked about I CD, he was shocked three times. The more we get hot shocked from your defibrillator, the survival rate goes down. And similarly, a FB atrial fibrillation. If they have heart failure and atrial fibrillation, the mortality rate rate goes up. So this guy Puga have all the bad signs for heart failure, also, the diuretic cues, the higher the dosage of diuretic that we give the worse the survival as well too. So when we're going up on the diuretics, 40 of Lasix twice a day, 80 twice a day amato zone at this and that it's a sign that we're developing what we call diuretic resistance. So it's important to monitor that because when patients are requiring more diuretic support, their overall survival is not. Well, also to renal insufficiency, this is important to monitor as well. If they're creatinine going up and if there's B UN going up, it's a sign they're not getting good perfusion to their kidneys. So all these parameters which might be subtle um are a sign and it's like a of a worsening and progression of their disease. So this is the, the thing I worked actually um on kind of pamphlet on my show later on is when to refer patients with advanced heart failure center. And there's something called I need help. And it's kinda like interesting because if every letter has a meaning I if they are on inotropes and if they're ny a class four, in the sense that they're symptomatic from their disease. E is a we worsening and organ dysfunction such as liver, they're becoming having liver congestion, liver enzymes going up, kidney function worsening. If the ejection fraction is less than 20%. If their I CD is shocking them. If they're having hardware hospitalization, if going on the diuretic if they're hypertensive, if they're not tolerating GDMT, if they're becoming, you know, taking their metoprolol off or the your interest to off, so they can, her blood pressure looks better on paper. All of these are signs of advanced heart failure. And when you have these patients, it's important to refer them to advanced heart failure center. And this is a nice figure. I'd like to show also frequently is that there is this sweet spot that we need to identify these patients. Most of the time when I'm on service or rounding in the hospital with our team, we got these calls and transfer from different hospitals, patients crashing and burning like they're in renal failure. They need a balloon pump or an impala and they cause for shock alerts. And at that time, most of these patients have been diagnosed with heart failure for years and years and years and they're not been seen by a specialist and they've been dwindling in their health. So there is this area where we need to catch these patients before they get worse. And this is why it's important to refer them to the heart failure center because I can speak at least from our own center, we can provide therapies that are not available. Otherwise we provide with cardio MS, for example, to help uh monitor these patient and outpatient setting to make sure that their volume uh is controlled. We can keep an eye on them. We pro do therapy, we do procedures such as heart biopsies if they ca if they have, for example, sarcoidosis or if they have myocarditis, we have a uh basically cardiopulmonary exercise testing. We can functionally asses do a testing to assess their functional status. We also have in our center, usually a dietician, a social worker, a financial counselor. All of these are resources for patients. We have palliative care team who comes in every Tuesday to meet with the patients because again, heart failure is a progressive disease. So it's important to at least build the expect, set the expectations and talk to patients when they're doing well before things get really bad. So again, these are kinda the highlights of patients. So what if the treatment fails? Three options? One of them is Miller know or inotropes and these medications do not improve survival. This is small band aid can make you feel better, try to keep you out of the hospital, but it does not of your survival. It is a bridge to either hospice or palliative care or a bridge for a heart transplant or an LVAD. Heart transplant is the best treatment modality that has shown to improve survival quality of life with the median survivor about 15% if they survive the first year. But again, survival on the heart transplant is lim uh heart transplant is limited due to donors. Heart available. We technically have around 50,000 patients with advanced heart fail every year, only around 4000 hearts are available. Again, we're doing more dual organs. But what about other patients who benefit from transplant? But they are not can for, they can't get a transplant. Vet, therapies have shown to improve survival and quality of life. Vet is left from TS device. And again, as you see here, the number of vets have come down because of the number of transplants to an up. But that is a viable options for these patients. And it's either as a bridge to transplant or destination therapies and patients on L VA usually they have five year survival of around 60%. So much better than 20% if you have hospitalized from heart failure. And finally, what happened to our patients? So he was admitted to the IC U. He had like on Miller infusion. He failed to be weaned off Miller renown. Um And this is uh his echocardiogram after he got an LVAD. I don't know if it shows here. This is uh the device that was implanted with this uh for this gentleman, it's in the top, in the LV apex. And what you notice if you notice something, if you looked at echoes the guy on the right, right side there, there is his aortic valve was not opening. So you can't have a a patient normal patients without opening of the aortic valve. Thank you so much for uh sticking in with us and have a good day. Thank you. Published November 5, 2024 Created by Related Presenters Amin Yehya, M.D. Sentara Advanced Heart Failure Center View full profile
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