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New Therapy Helps Treat Heart Failure Effectively
Mary Anne Papp, DO, FACC
Medical College of Wisconsin Cardiologist
Director of the Heart Failure Clinic
Heart failure affects 5 million Americans and an estimated 550,000 new cases are diagnosed each year. Millions more are at risk due to lifestyle factors that can be controlled. Mary Anne Papp, DO, FACC, discusses heart failure, its causes, risk factors, possible cures and an effective new treatment.
Q. What is heart failure?Heart failure is broadly defined as the failure of the heart to meet the demands of the body. By definition there can be two forms of it — the body is demanding too much of a normal heart (due to an accident that causes heavy bleeding, for example) or you can have failure of a heart to meet the ordinary demands of the body. The term “congestive” defines a commonly observed phenomenon where fluid retention is a visible sign of what may be heart failure, but it’s not necessarily. Congestive heart failure is defined as congestion in the lungs and both lower extremities unexplained by injury or other problems.
Q. Are there different degrees or types of heart failure?The American Heart Association and American College of Cardiology have defined stages of heart failure, and we consider people with risk factors to develop heart failure to be Stage A. Those risk factors are hypertension; diabetes; prior rheumatic heart disease; structural heart disease such as congenital defects; obesity; and the metabolic syndrome, where the waist circumference exceeds the hip circumference.
Stage B is a person who already has structural heart disease that can be identified with or without the congestive symptoms that we’ve talked about. Those people usually have a history of previous heart attack or a previous heart illness, but currently feel well.
Stage C is what we identify as patients who have known structural heart disease and are manifesting symptoms, including shortness of breath, fatigue, reduced exercise tolerance, inability to lay flat, increasing weight and swelling.
Stage D is a group of patients who have such marked symptoms at rest, despite therapy, and who are usually recurrently hospitalized because they cannot be effectively treated in the outpatient environment. The median age right now in the United States is 75, and some of these patients have multiple other organ failures. Options, such as compassionate end-of-life care or some mechanical measures might be considered. Hopefully, new therapies will develop for this group, but this is generally a population that is unresponsive to treatment and that requires specialized intervention.
Q. Whom does it affect? The genders are affected equally. There is a 2 percent prevalence among people between 40 and 59, with a progressive increase until the prevalence is 10 percent at age 70.
Q. What are the warning signs? If you’re diabetic, hypertensive, have metabolic syndrome or are at risk for coronary disease, you are already in Stage A and you should be addressing those factors. Warning signs that the heart failure is already Stage B or C include shortness of breath, swelling, inability to lie flat and rapid weight gain — more than 5 pounds in one week.
Q. Can heart failure happen suddenly?Yes, it can happen suddenly. Heart failure can happen with sudden severe shortness of breath, especially associated with chest pain. It can be the presenting sign of a heart attack. But usually heart failure is preceded by warning signs, shortness of breath, swelling, an inability to lie flat and others.
Once you’ve had a heart attack, by definition you already have structural heart disease and you’re in Stage B. If you get the symptoms, you’re in Stage C. A heart attack can happen and you can be in Stage B on the first day and Stage C on day two. A heart attack can be the most sudden onset of heart failure.
Q. Is it preventable?We believe that targeting hypertension, diabetes and metabolic syndrome can have the greatest impact on heart failure than any therapy. The success of such a regimen is best compared to our success with rheumatic fever. In 1950, rheumatic fever was the number one cause of heart failure. So, if we attack heart failure in Stage A, like we did rheumatic fever, we would be decades ahead.
Q. What causes heart failure and can it be cured?Hypertension, diabetes and metabolic syndrome are by far the epidemic causes. Chronic alcohol use is another well-known cause of heart failure. There are also some nutritional and metabolic causes, and fortunately, most of those are reversible with cessation of the nutritional, alcohol or metabolic load. You may actually see reverse remodeling of the heart back towards normal.
The goals for Stage A are to treat hypertension; encourage risk factor reduction for cholesterol heart diseases; treat lipid disorders; encourage regular exercise and smoking cessation; discourage alcohol and illicit drug use; and control the metabolic syndrome, which is the enormous obesity problem that we’re having in the United States right now.
So, certain viral, alcohol, nutritional and metabolic causes of heart failure are curable. Once fluid is controlled for other causes of heart failure, therapies like ACE inhibitors and beta blockers are known to be very effective in controlling and sometimes reversing heart failure.
Q. What is the newest treatment option? There is a new treatment called Aquapheresis™ for congestion and edema or swelling, the most common symptom of heart failure. Diuretics or water pills are the most common treatment for this symptom, but they stop working in Stage C and D patients for a variety of reasons. We call this the “braking phenomenon.”
Froedtert & the Medical College of Wisconsin have acquired new equipment called Aquadex™ that allows us to remove fluid in patients for whom diuretics have stopped working. Right now we’re only one of two centers in this region with the equipment.
Q. How does Aquapheresis™ work?It is achieved using peripherally inserted catheters, meaning standard intravenous catheters. The rate of fluid removal is accomplished in 10 to 24 hours at a rate of 500 cc per hour. That means a little over a pound an hour can be removed. Anywhere from 10 to 24 pounds of fluid can be removed in one treatment.
The benefit of this appears to last six to eight weeks, and the patients then seem to respond again to their diuretics or water pills. I participated in one of the clinical trials for the Aquadex™ equipment before coming to Froedtert & the Medical College of Wisconsin. There have been three major publications since December 2005, including FDA approval, showing that this one-day rapid fluid removal can have sustained, beneficial effects, making other therapies now effective. We instituted the therapy as soon as FDA approval was obtained.
This therapy differs from kidney dialysis. It is effective for patients whose kidneys have failed to respond to diuretics, but not appropriate for patients who are already on dialysis or nearing dialysis.
Q. What are the outcomes like?A gentleman we treated in February had 24 pounds of fluid removed, and he has not gained a pound back in eight weeks. His lifestyle is significantly better and he’s just thrilled. The treatment gives patients an opportunity to control some lifestyle factors and an opportunity to use drugs that were ineffective before because we couldn’t control the fluid. Now, they can be used and we get more benefit from the therapies we have.
There’s also an economic advantage. During a normal hospitalization for heart failure, more than 30 percent of our patients fail to lose even 5 pounds with diuretics — this is that failure of diuretics to be effective. In this therapy, the average weight loss achieved is more than 10 pounds in 24 hours, thus resulting in shorter hospital stays, more rapid improvement of symptoms and earlier institution of effective therapies that otherwise couldn’t have been used.
Q. How are patients referred for this new treatment? We are utilizing the Cardiac Second Opinion Program or Access Center so that patients can be referred quickly without repeating tests that have been done elsewhere. This therapy is administered in conjunction with their current physicians. The test is scheduled like an outpatient procedure with the intent of a less than 24-hour stay. Patients can be referred through the Access Center or they can request their own second opinion. In either case, we will attempt not to duplicate unnecessary testing.
Source: Every Day Date: May - July 2006 Issue | Medical Reviewer: | Mary Anne Papp, DO, FACC | | Medical College of Wisconsin Cardiologist |
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