Expert Perspectives on the Updated ACC Decision Pathway for Optimization of Heart Failure Treatment - Episode 2
The role of early aggressive treatment in preventing progression of heart failures and the importance of understanding the root cause of disease.
James Januzzi, MD: I’m going to ask a question that speaks a bit to treatment, which we’ll get to in a bit. What’s your perspective on whether earlier recognition of heart failure and earlier treatment might forestall the onset of severe symptoms or progression of disease? In other words, does earlier recognition and treatment have an impact on subsequent course of diagnosis?
Javed Butler, MD, MPH, MBA: There are 2 aspects to this. One is earlier treatment, and the other is aggressive treatment. If we start early treatment but treat at suboptimal doses or with suboptimal treatment, then the disease progresses. If you think about it, heart failure is the only major cardiovascular disease where we have made a certain exception. If you think about high blood pressure, diabetes, or dyslipidemia, how many of us will leave a person with systolic blood pressure of 180 mm Hg, a hemoglobin A1C of 10%, or an LDL [low-density lipoprotein] of 200 mg/dL alone because they are “doing OK?” The whole idea is to treat early and aggressively to prevent progression and complication. When it comes to heart failure, unfortunately a lot of times doctors think that if somebody is “doing OK,” treatment isn’t necessary. I know that you’re talking about early diagnosis, but the same concept applies to early treatment as well. Early diagnosis and aggressive early treatment can change the trajectory of the disease. It is an incredibly crucial issue. We are learning a lot from these recent trials that the benefit of therapy becomes statistically valid or statistically positive in less than 4 weeks. So it’s a big issue.
James Januzzi, MD: Getting the diagnosis confidently early on and getting therapy initiated and maximized is critically important. How do we make the diagnosis? What are the means by which a heart failure diagnosis is made?
Javed Butler, MD, MPH, MBA: We are focusing today on heart failure with reduced ejection fraction. There are some complexities for diagnosing heart failure with preserved ejection fraction, but maybe that’s for another day. The diagnosis is pretty easy for heart failure with reduced ejection fraction. If you are in a practice setting where an echocardiography can be performed, and your ejection fraction is not normal, then you have pretty much made the diagnosis. Remember that echocardiography is a completely benign test. There are no complications or risks to the patient. If you have the set of symptoms that are worrisome, like shortness of breath, fatigue, or the inability to perform activities of daily living, then you do an echocardiogram. If your ejection fraction is 40% or lower, you have your diagnosis right there.
If you’re in a setting where getting an echocardiography is difficult for whatever reason, and you want to screen which patients should get echocardiography, you can do a natriuretic peptide test. It’s a blood test that’s easy to do. If the natriuretic peptide levels are elevated, then you can triage those patients for an echocardiogram. There are certain subtleties. Sometimes it could be falsely low. You’re obviously an expert. There are a couple of pathways to go into the diagnosis.
James Januzzi, MD: Yes. And you beautifully articulated the just-published universal definition of heart failure. The global task force focused on establishing the structure and framework for defining heart failure has defined it as: symptoms, structural heart disease, or an elevated natriuretic peptide. Clinicians now have some guidance with respect to a more methodical way of establishing what exactly heart failure is. Because as you’ve said, the symptoms may be variable. They may not be as prominent early on, but earlier recognition and treatment would be expected to reduce risk for disease progression.
Javed Butler, MD, MPH, MBA: The other gap that we have in the diagnosis of heart failure is that once you have made the diagnosis, treating the patient early on with appropriate therapy is very important, but so is trying to figure out the cause of heart failure as well. Sometimes, we drop the ball there, ruling out ischemic heart disease. If somebody comes in with typical anginal symptoms, we evaluate for ischemia more frequently, but there are patients who may not present with typical symptoms. It’s important to see whether there is ischemic heart disease. In the appropriate setting, we worry about iron overload, thyroid dysfunction, valvular disease, pericardial disease, and infiltrative diseases. So make sure you also spend a little bit of time thinking about the etiology once you have made the diagnosis.
Transcript Edited for Clarity