Podcast 1: Pragmatic Overview of Heart Failure for Non-Specialists

00:00:00: You are listening to an ADIS Journal podcast.

00:00:31: in patients with diabetes.

00:00:33: In this first episode, we will discuss how clinicians can identify patients at risk of developing heart failure and ultimately how to prevent progression of heart failure in these patients.

00:00:44: Dr.

00:00:44: Enzuki and Dr.

00:00:46: Wright please introduce yourselves.

00:00:59: I've had a long-standing interest in the impact of diabetes and its treatment on cardiovascular disease.

00:01:27: Thank you!

00:01:29: As we all know, heart failure is one of the largest public health issues in the US.

00:01:34: Prevalence continues to rise as population ages and therefore incidence risk factors for heart failure such as hypertension diabetes kidney disease will also increase.

00:01:45: As an endocrinologist and a primary care physician firstly could you describe typical patient with heart failure that you diagnose?

00:01:55: And secondly how common it's for you see patients with undiagnosed heart failure in your practice.

00:02:01: Well, thank you!

00:02:02: The typical patient-with-heart failure seen in primary care is over sixty years of age more likely to be male and often a smoker.

00:02:11: I think it's worth mentioning that people from ethnic minority backgrounds particularly the black or african american ancestry And low social economic background are more likely.

00:02:24: The typical heart failure patient is also likely to have comorbidities such as hypertension, diabetes and obesity.

00:02:33: Obesity is a risk factor for developing hypertension and cardiovascular disease which are common risk factors for developing heart failure And it has also a risk-factor for developing Heart Failure independently of other cardiovascular risk factors.

00:02:49: On the second part of your question It is increasingly common to see patients with unrecognized and undiagnosed heart failure in clinic, in part due the complexities of diagnosing patients with multiple comorbidities.

00:03:04: For example, misdiagnosis or misdiagnosis of heart failure is common in patients with ischemic heart disease and lung disease.

00:03:14: Additionally, heart failure misdiagnosed as chronic obstructive pulmonary disease due to the overlapping symptoms.

00:03:25: I agree Eugene, we probably see at least a patient each day who might have undiagnosed heart failure or whose that risk for developing heart failure in next year.

00:03:35: often you pointed out with multiple comorbidities.

00:03:39: Heart failure is common complication of diabetes prevalent over one out every five patients type two.

00:03:47: Importantly, just having diabetes is considered stage A of heart failure and, of course, diabetes worsens the clinical trajectory with individuals with heart failure.

00:03:58: Chronic kidney disease or CKD is another important comorbidity to consider with heart failure.

00:04:05: Heart failure's present in up to half patients with CKd depending on the stage of the disease.

00:04:16: and heart failure occurs due to interdependent physiological processes, including impaired renal hemodynamics, eschemic injury, progressive left ventricular remodeling.

00:04:29: And ultimately cardiac dysfunction.

00:04:32: these disorders along with obesity can culminate into the so-called cardiovascular kidney metabolic syndrome or the CKM syndrome.

00:04:43: Instead of considering cardiovascular kidney and metabolic conditions in isolation, it's important for clinicians to recognize the interconnection between them.

00:05:13: could lead to earlier diagnosis and greater opportunity to intervene, to then prevent progression of heart failure as well.

00:05:21: I think this really underscores the importance early detection in screening.

00:05:26: Heart failure is a progressive condition with poor prognosis And patients with advanced stage heart failure have greatly reduced quality life.

00:05:37: By detecting and treating heart failure earlier and preventing or delaying progression there's a great opportunity to drastically improve the patient's quality of life.

00:05:48: A

00:05:48: good resource for primary care physicians, to determine what stage heart failure their patients have.

00:05:55: that I'd like to highlight is an infographic produced by The No Diabetes By Heart which is a collaborative initiative between the American Diabetes Association and the American Heart

00:06:06: Association.".

00:06:08: I agree Eugene.

00:06:09: I think this leads to something that might be underappreciated by both endocrinologists as well as primary care physicians, the very subtle presentation of heart failure initially.

00:06:21: As endocrineologists in our patients with type II diabetes we can be focused on identifying or preventing atherosclerosis and symptomatic coronary artery disease.

00:06:31: but actually heart failure can be the first presentation of cardiovascular disease in patients with type two diabetes.

00:06:41: And Nihar, let me turn it back to you as a cardiovascular specialist what are the early signs that endocrinologists and primary care physicians can be looking out for?

00:06:50: To help with the early identification of heart failure in our patients?

00:06:55: Thanks Silvio.

00:06:56: I think a good place to start would be a very quick recap.

00:07:04: refers to a patient who's at risk for heart failure.

00:07:07: This is asymptomatic, and as you said earlier, Sylvio includes patients with type two diabetes.

00:07:13: Stage B is pre-heart failure which includes people without symptoms of heart failure but with structural heart disease.

00:07:23: Stage C is symptomatic heart failure And stage D is advanced heart failure.

00:07:30: so people whose symptoms affect activities of daily living and who have repeated hospitalizations.

00:07:36: So by the time your patient is presenting with symptoms of heart failure such as shortness of breath, lower extremia edema signs of congestion they have likely already progressed to stage C. Heart failure is additionally classified according to left ventricular ejection fraction.

00:07:55: Heart Failure With a Reduced Ejection Fraction or HEF-REF is heart failure with a left ventricular ejection fraction of forty percent or less.

00:08:05: Heart Failure With A Preserved Ejection Fraction, or HEF-PEF holds when the ejection faction is at least fifty percent and an injection fraction that's between forty and fifty is classified as heart failure within mid range or moderately reduced ejection fractions.

00:08:23: It should be noted though these patients are likely to present similar symptoms such as fatigue, dyspnea and edema.

00:08:32: To your very good question Sylvia what can we do to catch these patients earlier?

00:08:37: And maybe prevent progression of heart failure?

00:08:40: I think the first thing we need to do is to recognize that patients with diabetes obesity hypertension coronary disease and others are at high risk for developing heart failure.

00:08:51: then we need.

00:08:56: So

00:08:58: based on that, Nihar now that we've identified the patient at high risk as a primary care physician or non-cardiologist specialist What screening and testing should we be focusing?

00:09:11: so I think biomarkers are really important to support the detection of cardiac dysfunction At an early stage.

00:09:18: Measurement of the naturally peptide Or high sensitivity cardiac troponin.

00:09:23: On at least a yearly basis is recommended to identify the presence of early-stage heart failure.

00:09:29: Assessing naturitic peptides may be done more frequently if there's a change in clinical status or concern for heart failure emerges.

00:09:38: Naturidic peptides are released from the heart and cleaved into the Hormonally Active B-Type Naturatic Peptide, or BNP ,and the Inactive N-Terminal Prohormone and T-pro.

00:09:57: BNP are viewed as comparable in their utility, in detecting heart failure but differ in their circulating levels.

00:10:05: So to determine heart failure risk.

00:10:07: a useful cutoff value for BNp is over fifty pika grams per milliliter.

00:10:13: For NTPROBNP this is over one hundred twenty five pika gramps per millilitre And for high sensitivity cardiac troponin it's over the ninety ninth percentile of the healthy patient population.

00:10:26: Serial measurements and looking at biomarker levels as continuous variables have been shown in clinical trials to be a key tool in early detection of heart failure.

00:10:36: I'll give you one example from the XAMIN trial, Impatience with Type II Diabetes.

00:10:43: two NT-ProBNP measurements spaced six months apart were able to identify risk for heart failure.

00:10:51: Those with two elevated measurements where it highest risk and those patients with an increased measurement relative to baseline had rising risk for heart failure.

00:11:02: It's also worth mentioning that biomarker results should be analyzed in the context of the complete clinical examination.

00:11:10: Factors such as age, the presence of kidney disease or atrial fibrillation may lead to increase levels of these prognostic biomarkers without necessarily being indication.

00:11:22: On the other hand, obesity may lower naturally peptide concentrations even if there is significant risk of heart failure.

00:11:32: Nehaar what are your thoughts on risk scores like the Timmy Heart Failure Risk Score or the Health ABC Risk Score?

00:11:38: Are these tools practical for us to use in a clinical setting?

00:11:42: Yeah it's great question Silvio I think they have some utility and really depends If you've had patient at the clinic and gone through step by thorough medical history, physical examination ruled out other potential causes for common heart failure symptoms such as edema which can also indicate cirrhosis or nephrodic syndrome, thyroid disease venous insufficiency among many others and then tested naturopaths peptides in biomarkers.

00:12:12: Then these are things that I would focus on.

00:12:14: but risk scores could be good for understanding how risk factors can exacerbate heart failure and then support clinical decision-making.

00:12:25: But which patients might qualify for an echocardiogram?

00:12:29: Would you suggest performing an echo on every patient deemed to be at high risk of heart failure?

00:12:34: Yeah, it's a really good question.

00:12:35: I think.

00:12:36: if you've identified a patient that had high risk they have abnormal natuorotic peptide or cardiac troponin levels.

00:12:44: At that point ecocardiography would.

00:12:47: the next step is An echo, of course will give you information on the cause-of-heart failure any structural functional cardiac changes that have already occurred and Of course we'll differentiate between half ref.

00:13:00: And half path.

00:13:02: But there's no need to delay the initiation of pharmacological intervention while waiting to complete an echocardiogram in The u.s.. We typically conduct laboratory testing and then refer for additional cardiac imagery again most commonly echocardiology in the appropriate context.

00:13:20: In other healthcare systems and potentially, in the future as imaging becomes more point of care one can envision a scenario where more screening is even done with echocardiography.

00:13:31: So once we've identified our patient who was at high risk We confirmed with biomarker testing an echo cardiogram.

00:13:40: moving forward What are these patients?

00:13:42: At higher risk of?

00:13:44: yeah There's often an early period of stability for patients with heart failure.

00:13:49: But we know that over time, there will be periods of decompensation and worsening symptoms with increased risk of hospitalization in death.

00:13:58: Earlier intervention can help to increase the period of asymptomatic clinical stability and delay onset progression of heart

00:14:07: failure.".

00:14:08: We've come up a nice stepwise approach here and intervene in heart failure earlier.

00:14:18: To summarize, step one medical history & physical examination looking out for diabetes kidney disease hypertension and obesity to identify those at high risk for developing heart failure.

00:14:33: Step two biomarker testing high-risk individuals At least annually so we can detect progression of heart failure as early as possible.

00:14:45: If biomarker testing is indicative of cardiac dysfunction, perform an echocardiograph.

00:14:51: In step four initiate intervention as soon as possible to delay progression of heart failure.

00:14:58: This should involve counseling the patient about what's being treated and why And need for lifestyle modifications like weight loss Smoking cessation Increased physical activity As well as importance medication adherence.

00:15:15: That's a really nice summary, Gene.

00:15:16: I hope that non-cardiologists listening to this can take away first how common heart failure is particularly in patients with diabetes CKD and obesity And second the tools are available to us so we can better screen for an identify Heart Failure in Patients In Our Practices.

00:15:37: Yeah It's A great Point and i think Sylvia linked To That point Is Really The Importance of Early Detection and diagnosis to improve outcomes, and prognosis for patients with heart failure.

00:15:48: So thank you so much Eugene and Silvio for joining me today.

00:15:52: I look forward to talking with you more in our next episode.

00:15:56: join us for Episode two of this podcast series where we will talk about guideline directed medical therapy for heart failure what pharmacological treatments are available for patients with heart failure and comorbidities such as diabetes, obesity.

00:16:40: The link to the article page can be found in podcast description.