Cleveland_Clinic_Host: Welcome Dr. Hobbs and thank you for being with us today. Let's begin!

Speaker_-_Dr__Hobbs: Thank you for having me.

Heart Failure - what is it?

SMITH77: I had bypass surgery in 88 and now I have swollen ankles and I am coughing up a lot of phlegm. I am on lasix. Is that heart failure?

Speaker_-_Dr__Hobbs: Swollen ankles can be a sign of heart failure but may also occur as a result of vein grafts removed from the legs at the time of bypass surgery. There are other causes of swollen ankles as well. Coughing up phlegm is usually not a sign of heart failure but more reflective of sinus post nasal drip or lung problems. Lasix is a general diuretic used to treat swollen ankles and fluid retention. It is not certain that heart failure is present. A bnp blood test may be helpful. An echocardiogram probably should be obtained if there is any question.

cindyak: What is the difference between heart failure and congestive heart failure?

Speaker_-_Dr__Hobbs: It is the same thing. The preferred term is heart failure because sometimes congestion is not present.

georgiaflo: My mom had heart failure. I have high blood pressure. Sometimes I get short of breath with some activities. I am nervous I am getting heart failure. How can I prevent it.

Speaker_-_Dr__Hobbs: First, blood pressure should be controlled. The ideal target blood pressure is 120/80, which is lower than previous values. You need to see your doctor for a check up and perhaps an echocardiogram would be helpful.

teresa: Can you please explain the stages of heart failure and what each of them mean?

Speaker_-_Dr__Hobbs: There are 4 stages of heart failure A to D.

Speaker_-_Dr__Hobbs: Stage A heart failure includes patients who are at risk for developing heart failure in the future but do not have heart failure at present. These may include patients with coronary artery disease, hypertension, diabetes mellitus, alcohol excess, or use of cardiotoxic drugs. Treatment of this stage is preventative.

Speaker_-_Dr__Hobbs: Stage B heart failure includes patients who have left ventricular dysfunction but no signs or symptoms of heart failure. These patients have low ejection fraction due to coronary artery disease, cardiomyopathy, hypertension, or other causes. Treatment includes preventative strategies, similar to stage A and drugs such as ace inhibitors and beta blockers.

Speaker_-_Dr__Hobbs: Stage C heart failure includes patients who have signs and symptoms of heart failure presently or at some point in the past. Treatment includes ace inhibitors, beta blockers, diuretics, and sometimes digoxin and spironolactone. In this stage, the use of defibrillators and biventricular pacemakers may be indicated.

Speaker_-_Dr__Hobbs: Stage D heart failure includes patients who are frequently hospitalized for decompensation. They usually have severe exercise limitations and prominent symptoms. Treatment includes all of the medications listed for Stage C but may also include high tech therapies such as cardiac transplantation and left ventricular assist devices. For patients who are not candidates for high tech therapies, referral to a hospice may be indicated.

teresa: How can one tell the difference between heart failure and respiratory conditions?

Speaker_-_Dr__Hobbs: This is difficult at times. The BNP blood test is often useful. A normal BNP level eliminates heart failure as the cause of breathlessness. Pulmonary function tests determine if there are lung problems causing shortness of breath.

ceinhorn: Does asthma have an impact on heart failure?

Speaker_-_Dr__Hobbs: Sometimes asthma symptoms may be caused by heart failure. This is called cardiac asthma. Patients may wheeze when heart failure decompensates. Heart failure and asthma can co-exist in the same patient. Some patients with asthma may not be able to tolerate beta blockers. Asthma itself does not adversely affect heart failure.

Devices: Pacemakers, Biventricular Pacemakers, and ICDs

hohndap: The above posted topic is for August 7, 2007, This is August 13. I wish to post a question to Dr. Hobbs on the August 14th topic on Heart Failure Treatment. I had a pacemaker implanted with the pulse rate setting of 70 to 130. Recently the pulse rate had registered quite often in the 60's. What is the significance?

Speaker_-_Dr__Hobbs: Perhaps a pacemaker check would be indicated here.

ceinhorn: Will an ICD or CRT due to cardiomyopathy (Phase II) and a low EF (15%) effect any positive changes as they relate to CHF? What are the risks?

Speaker_-_Dr__Hobbs: This is a complicated question. First of all, a defibrillator or biventricular pacemaker would not be recommended if the patient had asymptomatic cardiomyopathy.

Speaker_-_Dr__Hobbs: ICDs or defibrillators are now indicated for patients with dilated cardiomyopathy or ischemic cardiomyopathy (due to coronary artery disease) who have symptoms of heart failure and left ventricular ejection fraction less than 35 percent. These devices save lives by preventing sudden death due to ventricular arrhythmias.

Speaker_-_Dr__Hobbs: CRT or biventricular pacing is indicated in patients with severe heart failure, left ventricular ejection fraction less than 35 percent, and a wide QRS complex on the EKG. These patients should be on maximal medical therapy.

Speaker_-_Dr__Hobbs: 70 percent of patients improve after biventricular pacing but 30 percent do not. We can not predict who will respond to these devices. In some instances, the biventricular pacemaker and the defibrillator are combined into one unit, which as 3 leads positioned within the heart. These devices are very expensive.

Heart Failure, Diet and Exercise

quartersndimes: can heart failure pt safely use natural sea salt?

Speaker_-_Dr__Hobbs: Sea salt contains sodium chloride, therefore it is not any different than mined salt. Excess salt should be avoided in heart failure.

ann: If you have heart failure can you drink alcohol? I drink 1 or 2 beers a day, is that bad?

Speaker_-_Dr__Hobbs: Generally 1 -2 alcoholic drinks a day is permissible. The only exception is if cardiomyopathy is believed to be caused by alcohol excess. In this case, alcohol should be avoided completely. The daily alcohol limit is 2 five ounce glasses of wine, 2 - 12 ounce glasses of beer, or 2 - 1 and 1/2 ounce shots of hard liquor.

chris: I have been told to restrict fluids, what foods are considered fluids?

Speaker_-_Dr__Hobbs: Heart failure patients are usually instructed to limit fluids. Often 2 liters daily. This includes the usual liquids - water, coffee, juices, etc. But also includes fruits, soups, ice cream, etc. In order to calculate the daily fluid limit, one must take into account these other sources of liquid.

ann: should people with CHF exercise? Please discuss this

Speaker_-_Dr__Hobbs: Exercise is beneficial in heart failure. It does not improve the heart function such as the ejection fraction but it allows patients to become physically fit and to feel better. In the past, patients were placed at bedrest but this caused muscle deconditioning and worsened fatigue.

Speaker_-_Dr__Hobbs: Currently we recommend a program of light exercise such as walking riding an exercise bike, or water exercises. We also recommend a cardiac rehab program if feasible.

Heart Failure: Differences between Women and Men

stephanie: I read on your site that there are differences between men and women with heart failure. If I have 35% ejection fraction what medications should I be on? Should I see a special doctor for this? Not sure if I am getting the right medications.

Speaker_-_Dr__Hobbs: Men tend to develop heart failure at an earlier age than women. In men, coronary artery disease is the most common cause. In women, hypertension is the most common cause.

Speaker_-_Dr__Hobbs: Men tend to have heart failure with low ejection fraction. Women tend to have heart failure with normal ejection fraction but abnormal relaxation, called diastolic dysfunction. The prognosis is better in women than in men.

Speaker_-_Dr__Hobbs: An ejection fraction of 35% indicates moderate left ventricular dysfunction. You should be on an ACE inhibitor and a beta blocker.

Speaker_-_Dr__Hobbs: Most cardiologists can manage this situation.

Note: See Women and Heart Failure

Cardiomyopathy

kevin: My cousin had a virus and then got cardiomyopathy. That is scary - how often can that occur. What do you look for. He seemed like he just had a bad virus but then he didn't get better and went to the doctor and he has cardiomyopathy

Speaker_-_Dr__Hobbs: Cardiomyopathy may be caused by a virus in rare instances. The symptoms of heart failure would be shortness of breath, unusual fatigue with activities, and fluid retention. Any of these symptoms should prompt medical attention.

ceinhorn: I was diagnosed with cardiomyopathy in the early 1990's. I have been asymptomatic until about 2 months ago. I am having minor episodes of congestive heart failure. Is this the beginning of deterioration for me?

Speaker_-_Dr__Hobbs: You may be transitioning from Stage B to Stage C heart failure. This may require intensification of medical therapy. Reassessment by echocardiography is recommended. Often adjustment of the medications will result in stabilization and improvement of your condition.

Tom07: I have idiopathic cardiomyopathy. Can that be caused by environmental factors at my work, as I work around chemicals.

Speaker_-_Dr__Hobbs: Dilated cardiomyopathy is usually not caused by environmental factors including chemicals at work. In many cases we assume that the cardiomyopathy was caused by a virus although we cannot prove this. Sometimes cardiomyopathies can occur in families due to genetic causes. Cardiomyopathies can occur as a result of alcohol excess or certain cancer chemotherapy drugs. Hypertension that is poorly controlled may cause cardiomyopathy as well.

BNP and Heart Failure

tom2: What is the best way to diagnose if you have heart failure? What is BNP and if you have an elevated BNP and you take medications, do you get another BNP at a certain point?

Speaker_-_Dr__Hobbs: BNP stands for b- type natiuretic peptide. This is a blood test to determine if heart failure is present and to what degree of severity .A normal BNP blood test indicates heart failure is not present or not active. Less than 100 is normal.

Speaker_-_Dr__Hobbs: On the other hand, levels of 500 or greater indicate that heart failure is present and problematic. We use this test most often in the emergency department to evaluate patients who are short of breath. We may repeat the BNP blood test after treatment to see if levels decreased by half.

Speaker_-_Dr__Hobbs: Sometimes we use these tests in the office to assess the severity or presence of heart failure. These tests are usually not ordered regularly however.

Ejection Fraction

patrick45: Why does the ejection fraction bounce around? It was 15%, then 20%, then 18%- what does this all mean? Can ejection fraction improve with time?

Speaker_-_Dr__Hobbs: The ejection fraction varies throughout the day and long term. An ejection fraction within 6 percent is considered unchanged. The ejection fraction may improve with medical treatment. The ejection fraction may decline as the heart condition worsens. Patients often worry about minor changes in their ejection fraction. But heart failure specialists view only major changes as significant.

Herbal Remedies and Heart Failure

patrick45: What is the relationship between Coenzyme Q10 and heart failure?

Speaker_-_Dr__Hobbs: Coenzyme Q10 was thought to be useful in treating patients with heart failure. However, studies to date have failed to show any benefit or any risk. We generally do not recommend coenzyme q10 supplements.

jason77: I heard that there are some herbal medications that help people with heart failure, like Hawthorne Leaf and CoQ10 Alpha Lipoic Acid HCL. Are they helpful and do you recommend them?

Speaker_-_Dr__Hobbs: We have received a couple similar questions. There are no herbal medications that have been proven useful in clinical trials. We do not recommend any of these. Some herbal remedies may adversely interact with other prescribed medications.

Heart Failure and Diuretics

patrick45: I have been taking a diuretic and now it does not work well. I noticed from talking with others with HF, some people take the same dose everyday, some people take it according to their weight. If you take it everyday, does the effect wear off? Do you need to change the type of diuretic after you take it for awhile?

Speaker_-_Dr__Hobbs: There are many diuretics available with different sites of action in the kidney, different potencies and different metabolic effects. The most common diuretic used in heart failure is furosemide or Lasix. Usually patients take this once or twice a day. Sometimes an additional diuretic is given such as metolazone (Zaroxolyn) if the furosemide is not effective.

Speaker_-_Dr__Hobbs: If potassium is low, spironolactone, which is a weak diuretic may be given to keep potassium levels normal. Some doctors and patients initiate a program whereby the patient takes extra diuretic for swelling or weight gain. Ask your doctor if this applies in your case.

Speaker_-_Dr__Hobbs: Diuretics do not lose potency with time however the heart failure may worsen necessitating stronger diuretic dosages. Torsemide is a very potent oral diuretic that is sometimes used in severe heart failure when high doses of furosemide are ineffective.

Heart Transplant

jason77: I have CHF and my doctor tells me that I need a heart transplant. I have 15% ejection fraction. How long can somebody live with a 15% ejection fraction?

Speaker_-_Dr__Hobbs: A low ejection fraction of 15% does not necessarily mean that you need a heart transplant. Many people with similar ejection fractions are managed with medications and continue to function relatively well.

Speaker_-_Dr__Hobbs: The indications for transplant would be: poor functional capacity such as the inability to walk across a room without becoming short of breath; recurrent hospitalizations for decompensated heart failure manifested by fluid retention.

Speaker_-_Dr__Hobbs: The patient referred for heart transplant undergoes multiple tests and evaluations to determine if they are a candidate. An ideal candidate is a person with heart failure not responsive to medications who is otherwise healthy.

Enlarged Heart

Chris: Can you have an enlarged heart and not have poor heart function? If you have an enlarged heart and your function is normal now, are you at risk for problems later? Also, how does one get an enlarged heart to begin with?

Speaker_-_Dr__Hobbs: An enlarged heart is usually diagnosed on chest x-ray. This tells nothing about the heart's functioning. An enlarged heart may arise from uncontrolled hypertension in which the heart muscle becomes thickened but still functions normally. Other causes of an enlarged heart include valvular problems, old heart attack, cardiomyopathy, and congenital heart defects or disease. An echocardiogram is the best means of determining heart function.

Speaker_-_Dr__Hobbs: An enlarged heart is not a good sign regardless of the cause. It increases the risk of developing heart problems later. The cause of the enlarged heart should be worked up or evaluated. Specific treatment may be recommended depending on the cause.

Heart Failure Research

marcie1: I am interested in some of the studies going on currently with heart failure? How is stem cell going? What is immune modulation therapy? Are these, and any other approaches promising?

Speaker_-_Dr__Hobbs: Stem cell therapy is still investigational and is not being used routinely to treat patients with heart failure. The investigational studies are continuing but this therapy is not ready for general use.

Speaker_-_Dr__Hobbs: Immune modulation appeared to be promising initially but subsequent studies were disappointing. The future of immune modulation therapy is uncertain.

Heart Failure and Radiation Heart Disease

kas2004: What new medical treatments are available for patients with CHF, due to radiation induced hardening of heart

Speaker_-_Dr__Hobbs: Radiation heart disease is becoming more common as a result of patients surviving various cancers. Radiation frequently cures the cancer but causes scarring or fibrosis in the heart and the lungs many years after treatment.

Speaker_-_Dr__Hobbs: Management is the same as heart failure from other causes. Heart transplantation is very difficult due to the fibrosis of the chest and the lungs.

kas2004: Does the cleveland clinic have any on-going research is Radiation heart disease?

Speaker_-_Dr__Hobbs: We do not have research in this area. This type of heart disease is treated similar to heart failure from other causes. The damage was usually caused by radiation administered years earlier.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Hobbs is over. Dr. Hobbs thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Hobbs: Thank you for having me

© Copyright 2007 The Cleveland Clinic Foundation. All rights reserved 8/07