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Melanie Cole (Host): Heart failure is a condition in which the heart can’t pump enough blood to meet the body’s needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. My guest today, is Dr. Navin Rajagopalan. He is the Medical Director of Heart Transplantation and the Director in the Heart Failure Program at University of Kentucky Healthcare. Welcome to the show Dr. Navin. Tell us what is heart failure? What is congestive heart failure?

Dr. Navin Rajagopalan, MD (Guest): Thank you for having me. So, you summarized it pretty well there. So, when patients have heart failure; the heart is not pumping blood to the body efficiently and this leads to elevated pressures in the heart which can back up into the lungs and patients often develop fluid buildup in the lungs and they often have fluid buildup in the rest of their body, such as their abdomen and in their lower extremities. So, you are right. The heart -sometimes people argue that the term is a bit of an inaccurate term. The heart has not stopped. The heart has not completely failed. The heart is a pump and the pump is really not working efficiently the way a normal heart would work and this leads to fluid buildup in the lungs and in the body and this in turn causes patients to feel short of breath, develop weight gain from the fluid buildup as well as fatigue and just a general feeling of feeling unwell.

Melanie: So, Doctor, while you have cleared up that it is not the same things as a heart attack which people do confuse these two. But this can be considered a chronic condition, right now, because it is something that people live with and manage?

Dr. Rajagopalan: Yes, that is correct. Heart failure is a chronic condition and although some patients can improve dramatically; there is no cure, so to speak. And in fact, over the last five to ten years; our treatment for patients with heart attacks has greatly improved, such that 20 or 30 years ago, when somebody had a major heart attack; they would often die from that. Nowadays, we are doing a much better job of people recovering from their heart attacks but a lot of times patients are now left with a decrease in their heart function so they have a chronic condition known as heart failure. So, we are doing a very good job of keeping people alive after a heart attack and now we have more patients who have the chronic condition of heart failure.

Melanie: So, who is at risk for this?

Dr. Rajagopalan: So, the number one cause of heart failure is coronary artery disease, so that is blockages in the arteries that supply the heart. This often can occur after a heart attack when one of the arteries abruptly blocks and patients present to the emergency room with chest pain. But there are several patients where the blockages occur slowly over time, over five to ten years to fifteen years and then they develop shortness of breath or chronic chest pain and we find that they have diminished cardiac function. So, patients that are at risk for this often have history of smoking use, obesity as well as hypertension.

In addition, uncontrolled hypertension, so people who have a blood pressure that is running high and they are not aware of it can also develop heart failure. We do know that certain patients are at risk for developing heart failure; those that are overweight and lead a sedentary lifestyle and for some patients, there is no known cause. I often will see patients that are otherwise completely healthy, they have taken good care of themselves; and all of the sudden, they present with shortness of breath and their heart is not working well. And in those patients, we think that it could be a virus that attacked their heart or they had a viral infection and their body’s immune response got confused and started to attack their heart.

This is not very common, so I don’t want to scare people, but obviously those of us that work in major hospital systems will see patients like this every month and for some of these patients, there is no real cause and there is a lot of research being done as to what exactly causes heart failure in these situations.

Melanie: So, how do you diagnose it?

Dr. Rajagopalan: So, heart failure is predominantly a clinical diagnosis meaning that a patient will come to see their physician either in the emergency room or their office and say – and present symptoms of heart failure such as shortness of breath, swelling and often the doctor can examine the patient and see symptoms of heart failure or see signs of heart failure such as fluid in the lungs, pulsating neck veins which are a sign of fluid overload, swelling in the ankles and then a few routine tests will be done to confirm the diagnosis, this includes bloodwork as well as a chest x-ray and as well as a special test called an echocardiogram. This is a fancy term for an ultrasound of the heart. So, with an ultrasound of the heart which can be done at a doctor’s office or an emergency room; we can actually see the heart muscle squeezing and oftentimes, we will see that the heart is not squeezing as well as it should and that usually confirms the diagnosis of heart failure.

Melanie: So, if it is diagnosed, then let’s start with the first line of defense. What do you do for this patient so that they can manage this and hopefully get along with their life?

Dr. Rajagopalan: Yeah. So, when we diagnose a patient with heart failure; the first step is to determine the cause. So, as I said earlier, one of the most common causes of heart failure is coronary artery disease or blockages in the arteries supplying the heart. So, particularly if a patient has risk factors for coronary artery disease, even just their age, if they are over the age of 30 or 40 years old; we will often perform a cardiac catheterization where we look for blockages. If the patient has significant blockages and those are fixed; patients can often improve their heart function and they may no longer have heart failure. As with uncontrolled hypertension; if that is treated oftentimes we will see heart function improve. If there is no known cause of the heart failure or if patients get a stent and still have evidence of heart failure; then there are certain medications that can be started that can help control the symptoms and may, in some cases improve cardiac function.

Melanie: So, tell us about some of those.

Dr. Rajagopalan: So, the two major classes of medicine that have been shown to be beneficial for patients with heart failure where their heart function is reduced, are beta blockers as well as ACE inhibitors. So, beta blockers are medicines – or both classes of medicines help block some of the adverse hormones that long term can cause adverse effects on the heart. Some of the common beta blockers are medicines such as carvedilol, or metoprolol. Some of the common ACE inhibitors are lisinopril or enalapril. These medications are – have been around for decades and are fairly safe and all patients – and most patients with heart failure where their heart function is reduced, will benefit from these medications. There are several trials that have shown survival benefit and all of us who do this for a living, have seen patient who when started on medications, they really turn their life around and they are able to in some cases, improve their heart function.

Now when we say that there is no cure for heart failure; if a patient has had a good response to medicines we will often tell them that they need to stay on their medication lifelong in most cases. We feel that if they stop their medications that this condition may reoccur. The other class of medications that is often beneficial are diuretics. So oftentimes as I said earlier, patients will have evidence of fluid overload and so diuretics can be used to manage those symptoms. It is important to know though, that diuretics do not improve heart function, they are used to treat the symptoms, so medicines such as beta blockers and ACE inhibitors are medicines that actually can be used to help the heart beat more efficiently. Diuretics are used – such as Lasix or furosemide are used to treat the symptoms of heart failure but do not improve the heart function by themselves.

Melanie: So. Doctor, if somebody is on diuretics; then are there other things that you like to keep an eye on if they are on long-term diuretics, to keep that fluid down and out of their lungs; do we look at potassium, magnesium levels, keep track of certain things?

Dr. Rajagopalan: Yes. So, all of our patients that are on these medications, particularly in the early stages when we are seeing how the body responds, need to see their physicians rather frequently. I will have several patients that I see on a monthly basis and we get lab work when we see them to make sure that their kidney function and their electrolytes are working how they should. The one thing about diuretics is when patients have a lot of fluid, they may require a high dose of diuretics, but over time, we can reduce the dose. If patients are getting dehydrated, that can damage kidney function. If we back off too much on the diuretics; they can get a reoccurrence of their symptoms. So, patients do need to be watched fairly closely, but once we have them on a stable course and they are doing well; there are a lot of patients I see every six months and when I see them, they are doing well, but we just want to make sure that things are going well. Obviously, our patients also need to call us if they are doing well and then a month goes by and they have a change in their symptoms, because oftentimes that doesn’t mean their heart is getting worse; it just may mean that they need to get their medicines adjusted and so forth.

Melanie: So, then if it comes down to the meds not adequately providing the symptom management and management for the heart that you are looking for; what are some surgical interventions that might be necessary?

Dr. Rajagopalan: So, for most of our patients, we hope that medications will result in a near and a normal or near normal quality of life. If somebody has several blockages; that often can be treated with bypass surgery and those patients can improve heart function following bypass surgery. If somebody has heart failure due to a malfunctioning heart valve; that can be fixed surgically as well. There are devices now such as defibrillators that can also improve cardiac function. A defibrillator is a fancy type of pacemaker. Some of these devices will shock the heart if they go into an abnormal rhythm. Some defibrillators also can pace the heart in a more efficient manner that can also reduce symptoms of heart failure. For some patients, no matter what we do with their medications and the patients are taking the best care of themselves, they still have severe symptoms of heart failure and for some of these patients the only option is a heart transplant or a heart pump, otherwise known as a left ventricular assist device. Obviously, these are major operations and these are – would be considered a last resort for a patient. If a patient can do well with medications, that is obviously the ideal outcome. But we have several patients at the University of Kentucky where despite all of our best efforts; they still have a very suboptimal quality of life and for these patients, options such as transplantation may need to be considered.

Melanie: And what about lifestyle changes and behavior modification? What would you like listeners to know if they are somebody who is living with congestive heart failure; what would you like to tell them about things they can do at home?

Dr. Rajagopalan: Yeah, so not only obviously, we as physicians need to do our job with medications; but lifestyle changes which we should also tell patients about are also very important. These include proper diet and fluid restriction. Oftentimes heart failure can be controlled if patients reduce their sodium intake. Losing weight which obviously is hard to do is also a key component of heart failure management. I have had several patients that have lost 20-30 pounds through exercise and their heart failure symptoms become much less. And finally, exercise. Twenty or thirty years ago, it was felt dangerous for patients with heart failure to exercise. Now we know that that is completely opposite. It is actually very beneficial for patients with heart failure to exercise. We often will try to get our patients enrolled in cardiac rehabilitation so that they can be – they can exercise with a monitored environment if they are nervous about starting exercise. The heart is a muscle, so the best way to train a muscle that is not – that is inefficient or weak is to exercise. Obviously, this should be done under the supervision of a physician but I often will see a lot of patients that were told at some point that they should not exercise and actually exercise is very beneficial for patients with heart failure and there are several studies that have shown and proven that.

Melanie: So, tell us about some of your other clinical interests Doctor.

Dr. Rajagopalan: So, I am a cardiologist that is a heart failure specialist. So, as part of my training, I did an extra year of training in heart failure. That also provided me with experience with heart transplantation and mechanical circulatory support, also known as left ventricular assist devices. I have a special interest in patients who develop heart failure after pregnancy, which is called peripartum cardiomyopathy and I also, as I said earlier, as a transplant physician, I am very interested in advancing the field of transplantation and in seeing ways that we can improve survival following transplant.

Melanie: Thank you so much for being with us today Doctor. This is UK Health Cast with University of Kentucky Healthcare. For more information, you can go to www.ukhealthcare.uky.edu. That’s www.ukhealthcare.uky.edu. I’m Melanie Cole. Thanks so much for listening.