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Online Chat - Heart Failure: Treatment Options to Feel Your Best

Online Chat - Heart Failure: Treatment Options to Feel Your Best

Thursday February 17, 2011

Dr. Dickinson:
Hi, I’m Dr. Dickinson. Thanks for joining me today to learn more about treatment options for heart failure. Let’s get started!

Comment From Gordon Boucon:
I have no symptoms of CHF except strong fatigue that hits every day which makes me have to take a nap. Is this deep tiredness due to the disease or the strong beta blockers I'm taking?

Dr. Dickinson:
That is a very insightful question Gordon. Thanks for asking it. One of the three hallmark symptoms of heart failure is fatigue and beta blockers are very effective for improving heart function over time. So the fatigue really could be from your heart failure.

Dr. Dickinson:
On the other hand, beta blockers do cause fatigue in some patients. It is hard to know when a patient complains of fatigue which is the cause. Sometimes we try a different beta blocker (such as Toprol or Bystolic in place of Coreg). Sometimes we just try a brief reduction in dose to see if the fatigue improves.

Dr. Dickinson:
Regardless, this is a challenging question and is an issue best addressed with your doctor who knows all the details of your heart function and clinical course.

Spectrum Health:
FACT: There are approximately 5 million adults in the United States diagnosed with heart failure.

Comment From Gordon Boucon:
Nitrioglycerin tabs under my tongue help me to exercise - is there any reason not to use them if they help in this activity?

Dr. Dickinson:
Another great question Gordon. Nitroglycerin is generally safe and can be very helpful in heart failure as long as it does not lower your blood pressure too much. Nitroglycerin can help if you have a blocked artery. If it provides you benefit it could be valuable to discuss this with your doctor to make sure that there is not something else that might prove helpful (for example a stress test or heart cath/angioplasty, etc…)

Comment From Cindy:
What causes heart failure?

Dr. Dickinson:
There are many possible causes of heart failure, but the most common one is coronary artery disease. When there are blockages in the arteries of the heart, the heart muscle does not get enough blood supply to pump well. Also, those blockages can cause a heart attack. When part of the heart muscle is damaged or dead, the rest of the muscle has to work harder. Eventually this can cause heart failure.

Dr. Dickinson:
Another very common cause of heart failure is uncontrolled high blood pressure. High blood pressure forces the heart to work harder to push blood out into the rest of the body. Over time, the heart cannot keep up with the work load and heart failure results. Other causes may include heart valve problems, viral infections, heart rhythm abnormalities, excessive alcohol use and more.

Spectrum Health:
FACT: Heart failure is the most common heart-related reason that people are admitted to the hospital.

Comment From Louise:
What type of tests will I need to have if I have heart failure?

Dr. Dickinson:
You should have a thorough physical exam by your doctor first. Typically you will have some labs drawn, like a CBC (complete blood count – to check your hemoglobin and other things), a CMP (complete metabolic panel – looks at how your kidneys are functioning and electrolytes like potassium) and a BNP (b-type natriuretic peptide) which looks helps determine if your symptoms are caused by heart failure or something else.

Dr. Dickinson:
An electrocardiogram (EKG) will look at your heart rhythm and a chest x-ray will check for fluid build-up in your lungs. You will probably also need some type of stress test or an echocardiogram (an ultrasound of the heart) to see how well your heart is functioning. Other tests may be necessary, depending on the results of the first tests.

Comment From Gerald Stoddard:
I recently had another stent placed, after procedure in recovery I experienced chest pain and right arm pain that I never have had in the past. Since then I attempted to walk up a hill and had the right arm pain come back again. Could have a blockage moved during the procedure?

Dr. Dickinson:
That is a complex question Gerald. You are correct that sometimes cholesterol plaques can shift during angioplasty. Sometimes a small branch is sacrificed or "jailed" to protect a more important or larger coronary artery branch. It might be helpful for your doctor to try nitroglycerin or other medications. In all of this it is important that you discuss this with your doctor who could review your catheterization films and decide if any other treatment or testing is needed.

Spectrum Health:
FACT: About 550,000 new cases are diagnosed each year.

Comment From Ted Armstrong:
How often should a technician check my loop recorder?

Dr. Dickinson:
Thanks for your question Ted. That is a hard question to answer without knowing more particular details. If you have symptoms then you should discuss with the technician whether or not an interrogation is needed. Otherwise the doctor generally selects a period of time varying based on the condition that they are looking for.

Spectrum Health:
FACT: Heart failure is on the rise, but due to new and better treatment, survival is increasing.

Comment From Carol Conner:
At what point is fatigue judged severe enough to require a VAD?

Dr. Dickinson:
Hi Carol. An LVAD (or left ventricular assist device) is an artificial heart pump that can significantly improve energy levels. It does involve an open heart surgical procedure and so implantation is based on an assessment of mortality risk (i.e. we want to be sure the patient will live longer with the pump than without it). To assess for this we do cardiopulmonary exercise tests which provide us good information on functional capacity. We have specially trained staff to do these exercise tests at Spectrum Health.

Comment From Dianna:
I was diagnosed at an early age with CHF and cardiomyopathy. I finally received a bi-ventricular pacemaker that kept me off the transplant list. I recently had it replaced due low battery. I have been having trouble ever since. I feel all my old symptoms returning. I'm scared.

Dr. Dickinson:
I am sorry to hear that Dianna. Sometimes heart failure symptoms can recur despite everything working OK with your pacemaker. Sometimes the pacemaker needs to be optimized for you. This can be done by the pacemaker nurse and if you still are not feeling well, sometimes it needs to be done using an echocardiogram to fine tune the settings to match you. Please call your doctor and let them know that you are feeling this way.

Spectrum Health:
FACT: After heart failure is diagnosed, heart failure survival is poorer in women than in men.

Comment From Cindy:
How do you prevent patients with heart failure from suffering from hyponatremia?

Dr. Dickinson:
Hyponatremia is a medical term for low sodium. It can be caused by having too much fluid or too little fluid. It also can indicate severe heart failure. If your heart is very weak it is sometimes an indication that your doctors should reassess you to make sure that you do not need more advanced therapies (such as LVAD or transplant). Some patients are very prone to hyponatremia. There are some new medications that can help with this. Again, thanks for asking Cindy. I would encourage you to talk more with your doctor about this.

Comment From Bruce:
Have had 2 separate open heart surgeries; 1 in 1994 a double bye-pass and in 2008 single bye-pass and 2 valve repairs. I use cpap and oxygen at night only. When exercising on a treadmill, I get severe pain in the hips and lower back. Any thoughts to the pain? I also become fatigued easily.

Dr. Dickinson:
Hi Bruce. Pain in the buttocks or legs with exercise could indicate blockages in the arteries to your legs and back. We know that you are prone to arterial blockages based on your past history. Your doctor should check your blood pressure in your legs (ABI) or order an ultrasound study to make sure that you do not have peripheral arterial disease. Of course, arthritis, slipped discs and a whole host of other problems could cause your symptoms.

Spectrum Health:
FACT: Although the majority of people with heart failure are elderly, heart failure is NOT a natural consequence of old age and there are many young people living with heart failure, as well.

Comment From Dianna:
After treatment with pacemaker & medications, my heart has returned to normal size with a normal EF. With issues I'm having, is it possible that there is something else going on with my heart that? Maybe it's not the pacemaker at all. They keep tweaking it but without success.

Dr. Dickinson:
It is possible that there could be something else going on especially if your heart function is normal. It is also possible that there is a non-heart related problem that is causing your symptoms. Sometimes medication side effects can cause symptoms. Sometimes other medical conditions develop that mimic heart failure symptoms. That is why management of heart failure is always best a partnership between cardiology and internal medicine or primary care physicians.

When was the last time you had your blood pressure checked?

Comment From Dianna:
Are you confident that the cardiologists in GR have access to the newest technology and knowledge of CHF treatments?

Dr. Dickinson:
Interesting question Diana. Things have evolved and developed pretty quickly over the past 10 years here in Grand Rapids. GR has been a leader in quality and outcomes for heart disease but now we have pretty much everything we need for the patients of West Michigan. Of course our advanced heart failure program including LVAD and transplant has been a big step forward for us. Also our electrophysiology program has become one of the most sophisticated and busiest in the region. Yesterday one of our doctors implanted the first MRI compatible pacemaker. This was the first implant of this type in Michigan. Overall then I do have confidence in the level of sophistication that is now being provided. Thanks for asking.

Spectrum Health:
FACT: When your heart is functioning normally, it beats with enough force to shoot blood a distance of 30 feet.

Comment From Katie:
Does everyone that has heart failure need to be on an ACE-inhibitor?

Dr. Dickinson:
ACE inhibitors have proven to be very important for treating heart failure. They are most important in patients with reduced left ventricular ejection fractions. Angiotensin receptor blockers are alternative medicines which appear to be as good as ACE inhibitors. Some patients cannot tolerate ACE inhibitors because of weakness of the kidneys, high potassium, or low blood pressure. But yes - they are important and wonderful medicines for our heart failure patients.

Comment From Carol Conner:
Does a very high level of antibodies that prohibited a heart transplant also mean a problem in receiving an LVAD?

Dr. Dickinson:
Hi again Carol. Thanks for participating with us and say hi to Gerry for me. HLA antibody sensitization is NOT a limiting factor or problem for qualifying for left ventricular assist devices (LVAD). For those of you who don't know what Carol is referring to is that some patients have developed antibodies that make transplant difficult or impossible (antibodies that lead to too high of a risk of transplant rejection).

Comment From Dianna:
What is an MRI compatible pacemaker? Does it allow the patients to undergo MRI if needed for other reasons? Currently we cannot.

Dr. Dickinson:
You have it correct. With this type of pacemaker you could have an MRI if you needed to have one. There is a news release posted yesterday on the spectrum wealth website if you want to read more.

Comment From Veronica:
Can you explain what internal defibrillators are?

Dr. Dickinson:
Internal defibrillators (known as AICD’s – and acronym for Automated Implantable Cardioverter-Defibrillators) are amazing little devices that save lives. Sometimes people’s hearts go into an abnormal cardiac rhythm that, if not treated right away, will lead to death. AICD’s are implanted in the chest wall and small wires attach to the heart muscle.

Dr. Dickinson:
The AICD can “read” the rhythm of the heart and if it senses that there is a life-threatening rhythm, it will automatically deliver a shock to the heart, to try and “re-set” it to get the heart to beat normally again. AICD’s are frequently used in heart failure patients because they often have a low ejection fraction, which puts them at high risk for one of these lethal heart rhythms. If you have heart failure, or a family history of someone dying from sudden cardiac arrest (often described as a sudden massive heart attack) you should ask your doctor whether or not you are at risk.

Comment From Karthik:
I have type II diabetes, and have been trying to maintain a very strict exercise regiment to prevent this from leading to heart disease. I generally play tennis at least 3-4 times a week and occasionally run in-between on off days. My concern, though, is that "over-exercise" could accelerate any underlying heart conditions I may already have. Is this something I should be wary of?

Dr. Dickinson:
Significant exertion puts a temporary strain on the heart. That is why we recommend that patients starting an exercise program go slowly and gradually build up or get a check up with their doctor first. As long as you gradually build into your exercise program you should do fine and not harm your heart. In other words, we don't think that you can "wear out" your heart. Of course a racing heart over time from an arrhythmia can weaken the heart but generally we don't worry about this from regular exercise.

Spectrum Health:
FACT: The best way to prevent heart failure is to keep your heart healthy. Do not smoke, eat a healthy diet, exercise regularly, lose weight if needed, do not use illegal drugs, drink alcohol moderately and take prescribed medications as directed.

Comment From Hazel:
I know that if you have heart failure, you're supposed to be on a low salt diet. Why is that?

Dr. Dickinson:
Sodium (salt) has a natural attraction for water. If you eat a lot of salt, your body tries to “dilute” it by retaining water. (For example, that’s why you get really thirsty after eating a bunch of potato chips or pickles). In a person who has a normal heart and normal kidneys this process works fine and eventually he or she gets rid of the salt and extra fluid in their urine. In someone with heart failure, however, that extra fluid can overwhelm their weakened heart.

Dr. Dickinson:
Their heart cannot pump well enough to process the extra water and get rid of it. This causes blood and fluid to “back up” in their lungs and in other body tissues. When that happens, you start to see symptoms like shortness of breath and swelling in their legs or belly. Eating a low salt diet is one of the most effective ways to help manage heart failure. But – it’s also one of the hardest because a lot of the food in our typical American diet is very salty. We recommend no more than 2,000 mg (about 1 teaspoon) of sodium per day for someone with heart failure. That 2,000 mg includes the sodium that is already in food – not just what you add. If you are able to stick to that amount for a couple of weeks, your taste buds will adjust and you’ll actually be able to taste the flavors of your food better than you did before. A low salt diet is healthy other reasons, too – it can help prevent high blood pressure and lowers your risk for a heart attack and stroke.

Comment From Carol Conner:
If a pacemaker needs to have a new battery, is that an opportune time to switch to an MRI compatible pacemaker?

Dr. Dickinson:
I would think so Carol. This is all very new but we are hoping that over time there could be a transition to MRI compatible devices. At the time of pulse generator change would be an ideal time to make the transition as long as there is a device available that would meet the patient's needs. Your doctor would have to balance out the available technology to decide what the best device is for each patient.

Comment From Sally:
If I have heart failure, are there things I can't do anymore? Can I still drive?

Dr. Dickinson:
You should avoid activities that cause you shortness of breath or dizziness. Also, very strenuous exercises like running long distances or lifting weights are hard on your heart and should be avoided. Other than that, you can do your normal activities. If you start to feel symptoms, stop and rest. One of the keys of daily living with heart failure is learning to balance periods of activity with periods of rest. Walking is probably the easiest way to exercise. Check with your doctor before starting any new exercise program, but generally, it is important for people with heart failure to stay as active as possible.

Dr. Dickinson:
It helps keep your body (and heart!) in shape physically and is helps you stay positive emotionally and mentally, as well. A great way to exercise safely is to participate in a cardiac rehabilitation program. A cardiac rehab program will have specially trained staff who can help you develop a personalized exercise program and will monitor you while you exercise to make sure nothing goes wrong. I would highly suggest this, especially for someone who was recently diagnosed with heart failure.

As far as driving – heart failure does not necessarily keep you from driving. If you have frequent periods of dizziness or if you have fainted or “blacked out” you should NOT drive until you have been cleared by your doctor. Also, if you start any new medications, do not drive until you know how the medication will affect you.

Comment From Dianna:
It's sometimes difficult to exercise when you have CHF and feel so tired. What type of exercise would you recommend? Is it safe or can it aggravates the situation and make your symptoms worse?

Dr. Dickinson:
Good question Diana. We encourage heart failure patients to try to remain active but as in most things common sense prevails. It is possible to overdo it if you have heart failure. We call this "rebound fatigue" and patients know that they will pay for it if they push themselves too hard. You really need to listen to your body. If you are exhausted later in the day or the next day, it generally means that you pushed yourself too hard. We also talk about "energy conservation". This means that you need to set priorities for what is important in your day to get done and use the energy that you have for those activities. Exercise generally makes people feel better but if your heart failure is too advanced you have to go slowly and listen to your body.

Spectrum Health:
FACT: Heart failure may affect the left side, the right side or both sides of the heart. 

Comment From Autumn:
What are the most common symptoms of heart failure? How would I know if I had it?

Dr. Dickinson:
The most common symptom of heart failure is shortness of breath. In the earlier stages of heart failure, this may only be noticeable with activity. However, as the heart failure gets worse, you will notice shortness of breath even at rest. It often gets worse when you lie down. Shortness of breath is caused by a buildup of fluid in the lungs. The next most common symptom is swelling in the ankles and feet (called “edema”).

Dr. Dickinson:
Some people also experience swelling in other areas of their body, like their belly or hands. Most people will notice that they are very tired, as well. Other common symptoms are weakness, dry cough, depression, frequent nighttime urination, chest pain or confusion. For some people, symptoms come on gradually so they do not notice them right away. For other people, they are more sudden and easy to identify. Unfortunately, all of these symptoms may have other causes than heart failure, so it is important to discuss them with your doctor.

Spectrum Health:
FACT: The average American eats about 5,000 mg of salt per day, which is almost double the recommended daily allowance.

Comment From Gerald Stoddard:
Why is it that my emotions have been all over the place since I had my MI?

Dr. Dickinson:
I am glad you asked that. Depression is very common in heart disease including after a heart attack and in patients with heart failure. Some of this is related to the trauma of what happened to you. Some of it organic (i.e. related to physical changes that seem to trigger depression). Some of it may be related to medications.

Dr. Dickinson:
Because of this we at West Michigan Heart have entered into a joint venture between Spectrum Health and Pine Rest where we do depression screening and are now having patients seen by clinical psychologists in the CHF clinic. They can be seen under "health and behavior codes" that recognize that the depression is triggered by their heart disease AND that improvement in their depression can help their heart.

Spectrum Health:
FACT: People with heart failure are at a higher risk for sudden cardiac death (SCD). Automated Implantable Cardioverter-Defibrillators (AICDs) are often used to prevent the lethal arrhythmias (rhythm problems) that cause SCD.

Dr. Dickinson:
Gerald asked a follow up question about how to get treatment for depression. There are a variety of ways to be treated. Most patients call their primary care doctor as the entry into treatment for depression. We have our screening program at the CHF clinic. We are also using this screening in our ICD shock clinic (a special clinic that our patients go to after getting a shock from their ICD). We hope to expand this to the rest of the cardiologists in the Frederik Meijer Heart & Vascular Institute in the very near future also.

Comment From Dianna:
Does my cardiologist have to refer me to the Pine Rest clinic? Depression is a major factor with me.

Dr. Dickinson:
No your doctor does NOT have to refer you to Pine Rest. Many primary care doctors are comfortable managing common antidepressant medications. Some have psychiatrists that they refer to or partner with. The Spectrum Health CHF clinic has partnered with Dr. Jared Skillings who is a specialist in depression and anxiety that results from medical illnesses.

Spectrum Health:
FACT: Heart failure is more common than most cancers, including breast, testicular, cervical and bowel cancers.

Comment From Dianna:
I read somewhere that they are making pacemakers that can have the battery recharged without having to remove the old one - they are recharged outside the body. Is that true?

Dr. Dickinson:
There has been a LOT of things tried in this regard. In the past there were pacemakers that could recharge using "transcutaneous energy transfer". There were even some nuclear powered pacemakers! The enthusiasm for this has waned since the battery technology improved and the batteries started lasting longer (from 3 to 10 years depending on the device).

Dr. Dickinson:
Where the battery research is very active is in trying to get a fully implanted artificial heart pump (LVAD). There are a few companies that are hoping to perfect transcutaneous energy transfer. This is needed because these pumps draw more current.

Spectrum Health:
FACT: In the earliest stages of heart failure, you may not have any symptoms. Check with your doctor to see if you are at risk.

Comment From George:
I have been following the chat so far and I have a couple friends with heart failure, but I don't really understand it. Can you explain it?

Dr. Dickinson:
Heart failure does not mean that your heart has stopped, as the term seems to imply. It means that your heart is weakened and is not pumping as effectively as it should. The body does not receive the blood and oxygen that it needs, and fluid can start to back up in the lungs. This can cause a variety of symptoms. Heart failure cannot be reversed (unless you have a heart transplant) but it can be managed with a low-salt diet, a healthy lifestyle and medication.

Comment From Barbara:
Is there an age when it is more common to get heart failure?

Dr. Dickinson:
Heart failure can occur at any age. It is more common as people get older (from heart attacks or the long term effects of high blood pressure, etc...) Also older patients can experience heart failure with a normal ejection fraction (diastolic heart failure) as a result of stiffness of the heart muscle that comes on over time. It is important to know that viral infections and other problems can unfortunately cause heart failure at any age however.

Spectrum Health:
FACT: Spectrum Health has an accredited heart failure program and our heart failure program is West Michigan’s largest.

Comment From Dianna:
Is there a class that could involve a caretaker, to educate them about the issues with CHF, what to look for, how to care for - to help them adjust to the lifestyle changes?

Dr. Dickinson:
This was a strategic goal that we identified a few years ago. The IHI research tells us that patients who receive education in the hospital are sometimes too ill to retain the information. We assembled our "dream team" of nurses, dieticians, etc... who interact well with patients to put together a high quality class to meet this need? We now have the "Strengthen Your Heart, Do Your Part" class on a monthly basis. This is a GREAT class that we are pretty proud of.

Dr. Dickinson:
Thank you all for taking time to join me today to learn more about treatment options for heart failure. Please understand that it’s sometimes difficult to give detailed answers in this format, but I hope you all learned a little more about the condition and what you can do about it. HAVE A GREAT DAY!

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