Best Practices and Treatment Options to Manage Heart Failure - Episode 4
Transcript: Deepak L. Bhatt, MD, MPH: Akshay, these days, what do you think are the most common and important predisposing factors for heart failure?
Akshay S. Desai, MD, MPH: Deepak, I think that in the Western Hemisphere, the most important contributor is coronary heart disease. Patients with risk factors for coronary heart disease are at high risk for heart failure. I think about 40% of patients have ischemic heart disease as the cause of their heart failure, particularly in the setting of reduced ejection fraction [EF]. But even this group that Javed mentioned, the patients with preserved EF heart failure, there is a high overlap with ischemic heart disease. I think among those primordial risk factors, early cardiac risks, we’re particularly interested in the risk associated with hypertension, the contribution of diabetes and, increasingly, the contribution of obesity to the development of heart failure. What we know is that patients who accumulate more than 1 of these risk factors over time are at higher risk for developing heart failure over a lifetime than those with 1 or none of the risk factors. And that trend is true whether you’re a woman or a man.
In general, what we’ve learned is that the risk of heart failure should be identified early on from risk factors. That’s why the American Heart Association and ACC [American College of Cardiology] guidelines called out patients in stage A, who have no overt structural heart disease but do seem to be at risk for development of heart failure. We can identify those patients as targets for heart failure prevention.
I think as we’ll talk about a little bit later, one of the really exciting developments in the past few years has been the development of therapies, for example, for diabetes, that really are quite impactful in reducing the incidence of subsequent heart failure development over time. So those are some of the things I think we’re focused on now. Certainly, valvular heart disease and other specific risks are part of the etiologic spectrum of heart failure, particular in the setting of low ejection fraction. But I think when we’re thinking about big-ticket issues, it’s really cardiac risk factors and ischemic heart disease.
Deepak L. Bhatt, MD, MPH: George, maybe you can explain to our audience what the role of hypertension and hyperglycemia are in heart failure? When are lifestyle modifications not enough? When do we have to bump it up with medical therapy?
George Bakris, MD: As we just heard from Akshay, hypertension and diabetes are clearly the elephants in the room that predispose patients to heart failure, along with atherosclerotic disease. But historically, before this explosion of diabetes in the past 2 decades, hypertension, especially poorly controlled hypertension, was really one of the key contributing factors to heart failure. Obviously, regarding lifestyle modifications, very few physicians actually take the time to either send the patient to a dietitian or personally educate them on a low-sodium diet and the importance, in people with normal kidney function, of a balance between sodium and potassium in their diet. If patients actually do follow this and blood pressures are starting to rise above 130—especially for somebody with diabetes—I think it’s time to jump in and be more aggressive, even with monotherapy. You don’t have a level 1A trial but, as I tell the house staff, if you want to make sure the house doesn’t burn down, put out the fire when it’s in 1 room. Early, aggressive intervention is the way to go. And it’s not just blood pressure. It’s also glycemic control.
Deepak L. Bhatt, MD, MPH: Those are great points. You’ve often taught me through the years about salt abuse, as you call it, and the danger of too much salt and high blood pressure. And particularly in hypertension, it appears to be resistant. But what about in heart failure? Is it clear that salt restriction in the diet is useful?
George Bakris, MD: There’s no question in heart failure. If you look at specific pathophysiologic studies, even stricter salt restriction may be needed because of the underlying milieu that leads you to be even more sensitive to salt in terms of changes in the endothelium and what have you. It’s been said that in heart failure, you really should be close to 1 gram per day of sodium, rather than 2 grams per day. It doesn’t sound like a lot, but it actually translates into about 3 to 4 millimeters of mercury difference, which can make a difference in that state.
Deepak L. Bhatt, MD, MPH: Akshay, do you agree with the salt restrictions there? Is that what you’re telling our guys?
Akshay S. Desai, MD, MPH: I think it’s hard to disagree with George. The 1 thing that’s challenging is there’s sort of what’s ideal and then what’s possible. I think the average American diet is probably closer to 3.5 grams of sodium per day. So restricting patients to 1 gram or 1.5 grams per day, which I think is the formal American Heart Association recommendation, is actually quite challenging in this era of processed food. Most of us are not preparing all our own foods from fresh ingredients. It’s certainly an aspirational goal, and I think the less sodium, the better. The other thing we have to be careful about is understanding that salt restriction is particularly important for patients with established heart failure when the disease advances, and congestion and fluid overload are really driving worsening symptoms. So there, we’re particularly aggressive about encouraging patients to restrict salt to limit their tendency to decompensation. At the very front end, we’re talking about prevention. And there, it certainly helps but may be less urgent.
George Bakris, MD: And let me say, Deepak, I fully agree with that. I don’t want you to get the impression that I’m preaching 1 gram per day of sodium. I do preach this for people with advanced disease. But for prevention, I’m a 2-grams-per-day advocate, and I stay there.
Deepak L. Bhatt, MD, MPH: Actually, there’s nothing wrong if you want to preach, but the challenge is, will patients listen, or can they? Because as Akshay points out, in real life, it can be tough to do.
Transcript Edited for Clarity