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Melanie Cole, MS (Host): With the many advancements in medicine, management of heart failure has certainly changed over the years. Here to tell us about that is Dr. Clyde Yancy. He’s the chief in the division of cardiology, an associate director of Bloom Cardiovascular Institute at Northwestern Memorial Hospital. Dr. Yancy, this may sound like a weird question, but when did heart failure become sexy?

Clyde W. Yancy, MD, MSc (Guest): You know Melanie I am so pleased that we’re starting this way because it absolutely has become sexy. Now think about this, it is a play on words. Something that is sexy is exciting, it’s intriguing, it’s satisfying. Well for many, many years heart failure was anything but that. It was a dour, dismal diagnosis. There was very little that most people thought could be done. It really left the physician, and especially the patient, wanting an answer, wanting a solution. We have so many more questions to answer now and so many more opportunities. I really do think there is an excitement that gets close to what one would envision about a disease process, if it’s even possible, of becoming sexy.

Host: Why? Why is it sexy now? What’s changed over the years from the dour, dismal, “oh you have congestive heart failure. Now your life is going to be dramatically shortened.” What’s different now Dr. Yancy?

Dr. Yancy: So great question. The differences are in three big domains. The first one is that through science, we understand a lot more about what perpetuates the disease. Because of that, we now have a suite of therapies that are decidedly beneficial and can dramatically change the natural history. Second, when the disease continues to evolve, we have incredibly success that we enjoy now with therapies for advanced heart failure. Essentially, we are able to give people their lives back.

The part that really enthuses me the most, what I find to be the most exciting, is that this disease can absolutely be prevented. When you consider the power of prevention, the effectiveness of contemporary therapy, and the hope that we can hold out for those that even with advanced disease can get their lives back, this does become pretty sexy.

Host: And we are going to talk about prevention, and pretty much what you would like other providers to know about counselling their patients on that. But is it, if diagnosed, considered a chronic condition now just like arthritis or any other chronic condition?

Dr. Yancy: So, we don’t want to raise a victory flag and so we’re done. We've got this all figured out. But we’re so much further ahead than we were before. It is a chronic condition, but it’s to the extent now that many of us who have spent our careers doing this don’t like the idea of continuing to call it congestive heart failure or just heart failure. Because that implies that it’s still a failed proposition. We believe that we can treat this sufficiently well enough that it’s just heart muscle disease or cardiomyopathy. That nomenclature difference is not semantics. That’s a very important distinction because it means yes, the heart muscle is not completely normal. But no, there’s no longer overt evidence of failure. That’s an important shift in the way we think about this and the philosophy.

Host: In my intro, I said with advances in medicine it’s certainly changed over the years. What has changed as far as your treatment of heart failure? What is that like for the patient?

Dr. Yancy: So, let me begin by saying that I've had the privilege of serving as a chair person for the National American College of Cardiology and American Heart Association clinical practice guidelines on the treatment of heart failure for over five years. I can tell you with clarity that there are seven therapies that are appropriately indicated for heart failure because they change the natural history, help people live longer and live better. There are three devices that do the same thing and multiple other strategies. We have an entire menu now that we can select from.

So radically different from 20 years ago when many contemporary physicians were being trained where we had one or two, maybe three drugs and that was it with minimal expectation for good outcomes. So now we can literally talk about tailoring the treatment strategies to fit the particular patient. So, this really is, as I've said many times over, this is a new day in heart failure.

Host: Speak about some of those therapies and devices that you might look to. Let’s start with medicational intervention since you mentioned that. What’s new and different in the medicational intervention for heart failure.

Dr. Yancy: Yeah. So, because we now understand more about what drives a condition, we recognize that even though it begins with a mechanical problem where the heart muscle is damaged or injured, it is the heart’s response to that injury. A response that is characterized by elaborating a number of hormones, hormones that ultimately are counterproductive, that we’ve been able to intervene. Previously, all we used were ACE inhibitors, but now we have ACE inhibitors, or angiotensin receptor antagonist. We have beta blockers. We have aldosterone antagonists. We have the combination of hydralazine and isosorbide dinitrate. We have the powerful new drugs like ivabradine. And we have the new ARNi compounds, which is the combination of a neprilysin inhibitor, sacubitril, and an angiotensin receptor antagonist.

Those are a lot of words but sufficed to say seven proven to be effective therapies that changed the natural history. Different iterations, different combinations. We can come up with a strategy that works well for almost every patient whose heart failure is characterized by a weakened heart muscle.

Host: So, if medications aren’t effective on their own, speak about some of the procedural interventions that might be considered. Because there’s a lot of new ones now, and they are, as you say, very exciting.

Dr. Yancy: So, we've always known that we can attenuate one of the major causes of death in a setting of heart muscle disease, which is a sudden death due to irregular heart rhythms. We do that with implantation of a defibrillator for what we call primary prevention. We’re beginning to get much more clarity about which patient needs the defibrillator and which patient will do reasonably well with medical therapy. We know that certain pace making strategies are quite beneficial. We’ve known about cardiac resynchronization therapy for quite some time, but now we’re beginning to explore His bundle pacing, which may be just as good as and perhaps even better than cardiac resynchronization therapy more easily applied. So those are two strategies that we know we can use with devices.

The third strategy with device is implanting a pulmonary artery monitor permanently. It’s a very small device. It’s permanently implanted and the lung blood valve and continuously communicates with a receiver evidence that gives us a sense of what is the pressure within the lung circulation. So that using telemedicine, we can coach patients to increase or decrease certain therapies for heart failure that might help them feel better. Just recently a brand-new technology was approved by the FDA. A technology that provides an extra stimulus to the heart during a critical period in the electrical cycle, which can further improve cardiac performance uniquely indicated for a very narrow group of patients. I've just reviewed for you four devices, four ways that there’s evidence that we can improve the cardiovascular circumstances for the patient with heart failure. That’s in addition to the seven drugs. So, it really is pretty exciting.

Host: It certainly is. You mentioned one word that caught me, Dr. Yancy, and that’s telemedicine. As we've learned more and more about the benefits to providers and people in rural areas and now with heart failure, tell us where telemedicine comes in. You mentioned it briefly. Expand on it a little bit more and how that works with these devices so that it makes it a more efficient way of helping your patients.

Dr. Yancy: So, for heart failure, telemedicine has had some hits and misses. The hit has been in the incorporation of information we can extra from these devices into the overall approach using medicines, patient education, nurse management. Telemedicine per say as a tool independent of the input from the devices has not been as rewarding, particularly when it’s been deployed to reduce readmissions. For the information we can get from these contemporary devices, the pulmonary catheters, the resynchronization devices, even the defibrillators, we’re finding that we can amalgamate different fields of data from the devices along with ordinary conventional clinical data. And begin to really understand who is inclining towards becoming more ill, who is stable and doing well. So much of contemporary medicine is about using the out patient setting to optimize therapy, keep people in a position where their quality of life is adequate, and don’t have a need for the hospital.

Host: You mentioned readmissions, which seems to be an issue for certain conditions, but definitely for heart failure. Speak about the readmissions and what you're looking to, and even looking forward in the future to reduce those hospital readmissions for patients with heart failure.

Dr. Yancy: So, this is another area of intense focus in the field of heart failure. This has been an area that has incorporated a lot of my own research. Because we really are trying to understand what is it about the initial hospitalization that puts patients at such a high risk for repeat hospitalization so soon. Some of it is disease severity. Some of it is a process issue that needs to be refined.

We've taken a very novel approach at Northwestern and really have used some business theories that have to do with waiting in line for services and the load factors in a clinic setting. We’ve been able to use [inaudible] representations where we can match the capacity in the clinic with the necessity for services based on our patient profile. It’s a lot of words there but suffice to say using business theory we’ve been able to improve the efficiency of our clinics. In so doing, we have seen really significant drops in the rate of readmission.

The thing that really excites me though is that the recent data… Again, going back to the ARNi compound, the combination of the angiotensin receptor antagonist and the neprilysin inhibitor. Demonstrating that when that therapy is implied during the hospitalization as we had anticipated from an earlier study, the newest data—not even a month old—is telling us that that therapy may indeed be associated with a lesser need for repeat hospitalization. So, yet another important development in heart failure that we’re anticipating as we go forward.

Host: As we started this segment Dr. Yancy, you spoke about prevention. Can heart failure be prevented? More importantly, can it be prevented?

Dr. Yancy: So enthusiastically the answer is yes. In fact, over 50% of the episodes of heart failure can easily be prevented. I say that with such force because we know that hypertension is an important contributing factor to the burden of heart failure in everyone—male, female, black, white, across the board. We now understand that when we treat those persons uniquely at risk that is cardiovascular disease risk, treat the blood pressure appropriately with targeted blood pressure lowering—which we have learned from well done clinical trials—we can significantly, significantly being about a 40% reduction in the episodes of new onset heart failure.

That is enormously important because we understand that even with a first admission for heart failure, that patient’s natural history, their expectations of life and quality of life have begun to change. So, if we’re able to prevent that first admission, we can maintain quality of life, maintain the chances for good longevity. And in so, prevention and focusing on blood pressure, but no longer is it just blood pressure. The powerful new class of anti-diabetes drugs, sodium glucose transport inhibitors or SGLT2 inhibitors, have consistently now been associated with a reduction in the burden of new onset heart failure. That’s incredibly important news because it’s diabetes and hypertension that really predispose many patients to eventually developing heart failure.

The third part of that troika is obesity. Our own research has demonstrated that the three of those risk factors together—obesity, hypertension, and diabetes—describes the majority of risk for the development of heart failure, even when one considers the contribution of heart attacks and ischemic heart disease. So, we’re getting really, really close to having very effective tools to truly prevent this condition.

Host: Wow, that’s quite a statement. Really a very exciting time for cardiologists and physicians are dealing with heart failure. What would you like other physicians to know about Northwestern Memorial? Wrap it up for us with your best advice about why heart failure is now considered sexy.

Dr. Yancy: So, I'm going to give you three things. The first thing is that this disease can be treated and treated well with the correct deployment of evidence-based strategies according to guidelines, guidelines we helped generate here at Northwestern, we can fundamentally change the natural history. Second, I can assure you and all those that are listening that for the patients that have persistent symptoms, the therapies that are available—thinking about the Mitra Clip, repositioning the mitral leaflets and those with secondary mitral insufficiency, mechanical circulatory devices for those that have abject heart failure, even heart transplantation. Like many other sensors, those things are done well here at Northwestern.

The point that I want to leave the community with is about prevention. If we do our job as physicians and we identify these risk factors of obesity, diabetes, and hypertension and intervene accordingly, we can fundamentally change the natural history of this disease. Changing the natural history may not be that exciting, but when you reduce the burden of heart failure and realize how much more life and living you give to patients, that is exciting. That is important, and that is the message I want to leave everyone with.

Host: That was perfect. Dr. Yancy, thank you so much for joining us today, for sharing your expertise, and really discussing heart failure and what’s new and exciting in the field. So, thank you again for being with us today. For more information on the latest advances in medicine, please visit nm.org. That’s nm.org. This is Melanie Cole. Thanks so much for tuning in.