Expert Perspectives on the Updated ACC Decision Pathway for Optimization of Heart Failure Treatment - Episode 1
Javed Butler, MD, MPH, MBA, discusses the staging and difficulties associated with diagnosing heart failure.
James Januzzi, MD: Hello and welcome to this HCPLive® Peers and Perspectives® presentation entitled “Expert Perspectives on the Updated ACC Decision Pathway for Optimization of Heart Failure Treatment.” I’m Dr Jim Januzzi from the Massachusetts General Hospital Heart Center and Harvard Medical School in Boston. I’m joined today by my colleague and friend, Dr Javed Butler, professor of medicine from the University of Mississippi Medical Center in Jackson, Mississippi. Our discussion today focuses on the revised guidance that has recently been released by the American College of Cardiology [ACC] on optimizing the treatment of patients who have heart failure with reduced ejection fraction. Welcome, Javed.
Javed Butler, MD, MPH, MBA: It’s great to be here, Jim. Good to talk to you.
James Januzzi, MD: Let’s get started. Our goal today is to frame a discussion around what heart failure is, how we diagnose it, how we manage it, and the most recent evolution in the recommendations for the optimal medical care of patients with heart failure and reduced ejection fraction. Why don’t we start broadly? Javed, this is an area that you’ve been working in for a long time, but it helps people to get anchored in some of the basics first. Why don’t we start with how we diagnose heart failure? What are the symptoms? What are the tests we use? How do we stage heart failure?
Javed Butler, MD, MPH, MBA: This is an interesting question. Let me take the issue of staging for heart failure first. There continues to be a little bit of confusion about staging of heart failure and the New York Heart Association [NYHA] classification, which are completely different concepts. We have been thinking about prevention of vascular disease for a long time, since the Framingham Heart Study days. We worry about prevention of coronary disease, we worry about prevention of stroke, but we haven’t thought about prevention of heart failure as much.
Around 2005, we came up with a staging system: stages A, B, C, and D. This is around the continuum of risk for heart failure. Stage A are folks with hypertension or diabetes. They are at risk for heart failure, but they don’t have structural heart disease. Stage B is 1 step closer, you still don’t have heart failure syndrome per se, but you have structural or functional heart disease. You may have left ventricular [LV] hypertrophy, asymptomatic LV dysfunction, valvular disease, etc. Then you have stage C, which is what we perceive as run-of-the-mill heart failure, with symptoms like shortness of breath. Stage D contains the folks who are on optimal medical therapy, but have really advanced symptoms. Now you’re looking at advanced therapies like transplant or LVAD [left ventricular assist device], or unfortunately, if somebody is not a candidate, palliative care and end-of-life care. That’s the entire spectrum from risk to development to end-stage heart failure.
Whereas the NYHA classification is for people who have heart failure, looking at how symptomatic they are. When it comes to diagnosing heart failure, the common symptoms are shortness of breath, fatigue, tiredness, and the inability to be able to do what they were previously doing relatively easily. The symptoms are not very specific, and that’s precisely the problem: the diagnosis of heart failure gets delayed. Some of the symptoms are even more subtle: satiety, being short of breath in the middle of the night, and confusion. They tend to occur a little more in the advanced cases. Usual symptoms are shortness of breath, tiredness, fatigue. These can be very common. You see those symptoms with lung disease, anemia, thyroid problems, and many other things. For whatever reason, we evaluate all of these other differential diagnoses, and if we don’t find them to be the reason for the symptoms, we tend to blame things like obesity or aging, not realizing that 6 months ago, this person was equally old or equally obese. So what are these new symptoms because of?
Unfortunately, the No. 1 place where heart failure is diagnosed is in the emergency department, only because the symptoms have been going on in the outpatient setting for quite a long time without being diagnosed as heart failure until they go to the extremes. If we can keep heart failure in the list of our differential diagnosis, a lot of this can be diagnosed early in the outpatient setting.
James Januzzi, MD: That’s really useful information, Javed.
Transcript Edited for Clarity