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| The nation's #1 heart program by U.S. News & World Report for 13 years in a row! |
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Live Web Chat Transcript : David Taylor, M.D. |
Cleveland_Clinic_Host: Welcome Dr. Taylor , and thank you for being with us today. We look forward to an interesting chat today. Welcome! Let's begin with one of the questions! Speaker_-_Dr__David_Taylor: Thank you for having me. Heart Failure Treatment and Care tbwest: I have cardiomyopathy w/ CHF. Diagnosed at age 43 and am now 47. What should I expect from my doctor in regard to a "plan" for my future. I am currently being treated only with medication and regular PT checks. Speaker_-_Dr__David_Taylor: The intensity of follow-up and future testing obviously depends on the severity of the cardiomyopathy and the current symptoms that you have. Speaker_-_Dr__David_Taylor: For patients with mild cardiomyopathy whose symptoms are well controlled, we generally follow the patient with exams every six to 12 months and often echocardiography every 12 to 24 months. Occasionally we may perform other cardiac tests, such as exercise tolerance tests to assess stability. Patients with more advanced symptoms or lower ejection fractions may require much more frequent screening. millieme_2: if one has cardiomyopathy and has been in heart failure with EF of 22 and now on meds and EF around 40, but lab does not show a problem and yet symptoms of short of breath and weakness w/fatigue, light headness, leg and ankle edema, what would cause these symptoms if test do not show one is in heart failure Speaker_-_Dr__David_Taylor: What I suspect the "lab" that you are referring to is the B-type natriuretic peptide (BNP) level which is elevated in active heart failure and low in normal people. However, the test is not 100% accurate so we do occasionally see elevated BNP levels in people without heart failure and "normal" levels in patients with heart failure. The test is less accurate in patients with heart failure who have higher EF. Speaker_-_Dr__David_Taylor: EF (ejection fraction) is simply a measure of how much the heart contracts (squeezes) with each beat. Normal is 55-70% (left ventricle ejects 55-70% of the blood that it contains with each beat). Heart failure can be caused by a low EF (poor contraction) but also occurs in patients with normal EF when the heart is "stiff" or doesn't relax well. In fact, half of the patients admitted to the hospital with heart failure have EF greater than 40%. Speaker_-_Dr__David_Taylor: Also, keep in mind that many things cause shortness of breath, weakness, fatigue, edema, etc (the common symptoms of heart failure), including rarely the medications used to treat the HF. Beta-blockers, an essential treatment for heart failure with low EF, often cause some fatigue and lower blood pressure. Speaker_-_Dr__David_Taylor: ACE-inhibitors, another essential treatment for heart failure with low EF, often cause low blood pressure (which can cause lightheadedness). Fluid pills (diuretics) can also cause fatigue and lightheadedness if they remove too much fluid (dehydration). kjf52: My mother has not been feeling well and she went to the doctor. After many tests they told her her heart muscle is week and only functioning around 20%. What does that mean? What would be the treatment for that? We are not sure what to do? She has a cardiologist – but should she go to a heart failure cardiologist? Speaker_-_Dr__David_Taylor: Please see our website on the section of Heart Failure. Many things can weaken the heart muscle, including but not limited to - poorly treated high blood pressure, heart attacks, viral infections, and hereditary disorders. Speaker_-_Dr__David_Taylor: There are a variety of treatments depending on the cause of the cardiomyopathy (weak heart muscle). I assume that the cardiologist will have done various tests to attempt to determine the cause and have begun heart failure treatment. This includes drugs, specifically used for the treatment of heart failure including diuretics (fluid pills); beta blockers; and drugs in the family of ACE inhibitors. Sometimes defibrillators or pacemaker therapy is needed. And - in some situations - cardiac surgery including cardiac transplantation may be necessary. Speaker_-_Dr__David_Taylor: Although all cardiologists take care of patients with heart failure and do an excellent job, it is often beneficial to see a heart failure specialist for additional information, education, and other treatments - particularly in patients who are not responding well to the current therapy. marathonrunner: My dad was just in the hospital. He was told his EF is 15% - they told him there is nothing they can do – basically go home and die. Is that it? Are there other options for someone like that. He is 68 years old. Speaker_-_Dr__David_Taylor: Without knowing the complete details of your father's case - it is difficult to discuss all the possible treatment options. However, a 68 year old patient with end stage heart failure might be a candidate for advanced therapies such as a mechanical assist device or cardiac transplantation. In addition, some specialized heart failure centers may have ongoing research protocols that could be of benefit. tbwest: In regard to my previous question about long term treatment, my EF is 20% and has been since Aug. 2004. Speaker_-_Dr__David_Taylor: If your symptoms are reasonably well controlled and you are taking recommended doses of beta blockers and ACE inhibitors, in addition to perhaps additional medicines, then periodic follow-up for signs of deterioration would be the goal. With an ejection fraction of 20% I assume you already have a defibrillator. We would monitor your case for signs of deterioration that would lead to the consideration of advanced therapies such as cardiac transplantation or mechanical assist devices. Speaker_-_Dr__David_Taylor: It is recommended that the current medications used for heart failure treatment be continued indefinitely regardless of whether someone improves or does not improve. happyday: Is it possible to have cardiomyopathy, had heart failure and blood test for heart failure is negative and still have symptoms,even with beta blocker, lasix,vasotec, coumadin for a-fib and stroke. Heart little enlarged, leg and ankle edema. Speaker_-_Dr__David_Taylor: There is no completely accurate blood test for heart failure. What I suspect you are referring to the the B-type natriuretic peptide (BNP) level which is elevated in active heart failure and low in normal people. However, the test is not 100% accurate so we do occasionally see elevated BNP levels in people without heart failure and "normal" levels in patients with heart failure. Heart failure is what we call a "clinical diagnosis". That means that the diagnosis is made by a constellation of symptoms, examination findings and diagnostic tests. Remember there are multiple causes of leg and ankle edema, shortness of breath, and fatigue (common heart failure symptoms) in addition to heart failure. Usually advanced testing such as echocardiography (cardiac ultrasounds) and stress testing can help differentiate heart failure from the other non-cardiac causes. cyb1127: Dear Dr. Taylor , I am a 61 year old female. I had two heart attacks almost 17 years ago. i had a double by-pass in 1991 and a single by-pass with a mitral valve repair in 1994, the second one at the CCF. I have CHF and severe left ventricular dysfunction. I have a bi-V pacemaker and an ICD. At the present time my EF is about 35, 11 without assistance. I have been told I am not a candidate for any more surgery so my question is what is there out there that could benefit me in the future? Speaker_-_Dr__David_Taylor: There are a variety of additional strategies that may benefit patients such as you in the future. Currently, heart transplantation offers an excellent quality of life and prolonged survival for patients with end-stage heart failure. Mechanical pumps have improved significantly over the recent years and are now being used to stabilize patients waiting for heart transplantation (called "bridge-to-transplant" therapy) as well as a permanent therapy for patients not candidates for heart transplantation. Smaller, better devices are in development today. We expect to see these type of pumps used more frequently in very near future. Cell transplant (sometimes called stem cell transplant, which involved injecting or infusing cells directly to the damaged heart muscle) and gene therapy (injecting genes directly into the heart cells to improve function) are both moving forward in experimental trials. Within the next 5 years we should understand their potential role in the treatment of advanced heart failure. Since all of these are still experimental or higher risk, they are currently reserved for patients with severe, advanced disease without other treatment options. Hopefully in the future if successful we can expand their use to patients with less advanced disease at an earlier stage of their disease. wmrock: Would a patient with CHF also have some problems with confusion and short term memory loss? Speaker_-_Dr__David_Taylor: Yes - patients with heart failure can have these problems - sometimes related to the heart failure itself and sometimes related to the medications needed to treat it. Generally, as the heart failure improves, so does the confusion and memory loss. Obviously there are many other causes for these which should be investigated dandan: How is ischemic cardiomyopathy treated? My dad has it and I wonder what I should be looking for him for treatment? Speaker_-_Dr__David_Taylor: Ischemic cardiomyopathy is due to coronary blockages. In some cases, angioplasty or bypass surgery may be helpful. Speaker_-_Dr__David_Taylor: In all cases, medical treatment with beta blockers and ACE inhibitors and occasionally diuretics, digoxin, and aldosterone blockers are helpful. Simply put - the treatment is the same as with other forms of congestive heart failure. tbwest: With EF at 20% w/ severe left ventricular dysfunction (also had blood clot in left ventricle), do I fall in the category you referred to as "end stage" heart failure? Can you explain what end stage means and what should be done? Speaker_-_Dr__David_Taylor: I would recommend seeing a cardiologist regarding your questions about the device and your heart failure status. Causes of heart failure barbara44317_2: hi, dr thank you for taking this time to answer are questions, my dad who is 74 has really high blood pressure its 202/101 most of the time and he has a right bundle block can either of these lead to heart failure? Speaker_-_Dr__David_Taylor: High blood pressure (hypertension) is a common cause of heart failure. However, with successful treatment of hypertension the risk of heart failure decreases significantly. In addition, with successful treatment of hypertension, already existing heart failure often improves substantially. Hypertension also increases the risks of stroke and heart attack. Thus, adequate control of blood pressure is very important. Right bundle branch block does not cause heart failure. It can even be found in up to 10% of healthy young people up to 10%. tomcat: Somebody told me if you have a heart attack and then damage your heart – that some of it may come back and function better – is that true? Speaker_-_Dr__David_Taylor: During a heart attack, some of the muscle is permanently damaged and some is only stunned or even what we call hibernating. Therefore, with time and improving the blood flow to the damaged area, the function of that area may improve. relaxinsun: I have valve disease for a long time. My doctor said I now have heart failure. Is that caused by valve disease? If I fix the valve will the heart failure go away? Speaker_-_Dr__David_Taylor: Long standing valve disease can cause heart failure. Likewise, long standing heart failure can cause valvular disease. It becomes the chicken and the egg dilemma sometimes deciding which is the cause and which is the effect. Speaker_-_Dr__David_Taylor: Regardless, certain valve abnormalities can be addressed surgically and improve the heart failure syndrome. Speaker_-_Dr__David_Taylor: Occasionally, the damage to the heart muscle is too far advanced for the valve surgery to provide benefit and in those cases, consideration for other advanced therapies should be considered. stephb: My brother was diagnosed with cardiomyopathy. Does that run in families? Should I get checked somehow? What are the signs? Speaker_-_Dr__David_Taylor: It is estimated that 30 to 50 percent of what we generally call idiopathic cardiomyopathy runs in families. That means that 50 to 70 percent of cases are sporadic. Speaker_-_Dr__David_Taylor: If there are more than one family member with cardiomyopathy then the chances of it being genetic increase. In these cases, one might recommend screening the first degree relatives (brothers, sisters, parents, children) for possible cardiomyopathy. Speaker_-_Dr__David_Taylor: Generally, this would be done with an echocardiogram and an electrocardiogram. At the present, there is no simple genetic screening test available. marper: Suffering from high blood pressure 150/110 for al least 10 years - only 2 weeks ago finally down to 130/90 - and although not being diagnosed with HF several years ago - how likely is it to get HF? Has high blood pressure (150/110 - 130/90) - had blue feet at 4am due to the BP being lowest around that time. How likely is it that this is also an indication of HF? If this person (150/110 - 130/90) is slowely being developed, this person has a history of fluid retenition with ACE inhibitors and also with HCTZ (diuretics) strangely enough. Is currently taking a first generation AIIA and BP is possibly going down (after 10 years). What kind of medication would be good for such a person? Although if fluid retention is caused by an ACE inhibitor it possibly suggest it can't be HF? Speaker_-_Dr__David_Taylor: Similar to my comments to question 1 above, hypertension can lead to heart failure if left untreated adequately. Although you have had some difficulties with several anti-hypertensive drugs, luckily there are many more to choose from. The "AIIA" or ARB (angiotensin receptor blockers) are an excellent class of drugs. The calcium channel blockers and the beta-blocking agents are also successful. In addition there are many more choices. Speaker_-_Dr__David_Taylor: The current research suggests that the actual drug type is much less important that actually controlling the blood pressure. While fluid retention can be a sign of heart failure, there are many other causes, including medications as you point out. Heart Failure and Device Therapy (Biventricular Pacemakers and Defibrillators – ICD) my_joy: does the same recommendation of "40 days" also apply to patients who have experienced cardiac arrest? What is the likelihood the EF will rebound back to a normal or acceptable level? Speaker_-_Dr__David_Taylor: I believe you are referring to the recommendation of placing a defibrillator to prevent sudden death in patients with low EF (ejection fraction) who have suffered a heart attack. Once a patient has a cardiac arrest, the criteria for placing a defibrillator changes. There are several types of "cardiac arrest" and it would depend on the exact cause but often the "40 day" criteria is not necessary when placing a device after a cardiac arrest. Patients who have already suffered one cardiac arrest are at much higher risk to have another, thus more likely to benefit from the defibrillator. Speaker_-_Dr__David_Taylor: In regards to improvement in EF, depending on a variety of factors, EF will sometimes increase substantially (even back to normal) after longer follow-up and treatment. However, sometimes one cannot take the risk of another cardiac arrest while waiting for improvement. Thus occasionally a patient receives a defibrillator after a cardiac arrest and later on the heart improves substantially to the point where the defibrillator is no longer necessary. However there is a risk associated with procedures to remove the device, so often it is simply left in place. ben: I have heard of a biV device is good for heart failure patients. But when I suggested it to my doctor. He said that was not for me. What is it and why is it good for some people with heart failure and not with others? Speaker_-_Dr__David_Taylor: To learn more about the biventricular device, please look at our website - http://www.clevelandclinic.org/heart - look in the heart guide under heart failure. Speaker_-_Dr__David_Taylor: In brief, patients with heart failure and low ejection fractions sometimes have slow electrical conduction through the heart muscle tissue. This leads to a delay in the contraction of the farthest sections of the heart. Sometimes a pacemaker can be placed with its lead in the farthest region to allow near simultaneous contraction of the heart muscle leading to improved function. Speaker_-_Dr__David_Taylor: There are a variety of criteria we look at to judge the potential benefit of such a device.For patients who are appropriate candidates, over 70 percent achieve a significant improvement in their symptoms. tbwest: Yes, I am taking the medications you described, but do not have a defibrillator. Am being seen by an internal medicine doctor. Should I see a different doctor or ask my current doctor about a defibrillator? Last echo. showed EF or 20% and Severe left ventricular dysfunction. Speaker_-_Dr__David_Taylor: Yes. You should see a cardiologist about the potential benefit of a defibrillator. Heart Failure and Research (stem cell therapy) hf40: What is going on with stem cell therapy? What types of research is going on for heart failure? Speaker_-_Dr__David_Taylor: The stem cell therapy field is an active area of research. At this time, many centers including the Cleveland Clinic are investigating the potential benefit of cell therapy in advanced heart disease. Speaker_-_Dr__David_Taylor: At the present time, studies are underway to determine the best type of cell to use, the best way to administer the cell, and the most appropriate dose of the cells. If you want more information about active studies, you can contact us - using the contact us link on the website. Speaker_-_Dr__David_Taylor: There are a variety of other types of research protocols ongoing in the heart failure arena. Several involve new drugs and gene therapy protocols have also begun. You can go to http://www.clinicaltrials.gov and search on heart failure to see current studies. B-type natriuretic peptide (BNP) missytrexel: My dad has been diagnosed with CHF and his BNP # is between 300-350. What stage of heart failure is this considered. I'm not sure if I have the correct name for the lab that they did on my dad. Speaker_-_Dr__David_Taylor: BNP is a protein liberated from heart muscle under stress. Normal BNP levels are generally below 100. Once abnormal, the level does not predict the severity of the heart failure. For example, patients can have advanced heart failure with levels between 200 to 600 and patients can also have minimal active heart failure with levels in the same range. Speaker_-_Dr__David_Taylor: Thus, we use the BNP level as a thermometer to monitor patients progress but it is not a direct measure of heart failure severity. Heart Failure and Herbal Supplements kjk52: Are there any medications or supplements you can take to improve the heart function – I have heard of CoQ10 and also hawthorn extract can help with heart failure patients. What do you think? Speaker_-_Dr__David_Taylor: This is a very common question. However, most of these supplements have been poorly studied in cardiac disease patients. Speaker_-_Dr__David_Taylor: CoQ10 is one of the best studied yet the data is sparse. In animals with heart failure CoQ10 appears to improve cardiac function. However, in human trials no such benefit has been found.On the contrary, no evidence of harm has been found. Speaker_-_Dr__David_Taylor: There is even less data on hawthorn berry and at this time I do not recommend it as a treatment for heart failure. Diastolic Dysfunction jean1226: I was recently diagnosed with diastolic dysfunction. I cannot find much about this. What is it and how is it treated? What is my prognosis? Speaker_-_Dr__David_Taylor: Over half of patients admitted to the hospital with heart failure have so called diastolic heart failure. Speaker_-_Dr__David_Taylor: That simply means that the ejection fraction or the pumping function of the heart is relatively well preserved. The difficulty lies in the stiffness or relaxation of the heart muscle. Speaker_-_Dr__David_Taylor: High blood pressure is a common cause of diastolic dysfunction. It is treated similarly to "systolic heart failure" or heart failure related to poor contraction. Speaker_-_Dr__David_Taylor: The prognosis depends on the severity and cause of the diastolic dysfunction. Heart Failure and Chemotherapy Webquestion: I have a close friend who had a double mastectomy 15 years ago with high dose adriomycin which, I am told, can cause heart damage up to 20 years after treatment. My friend is in her early 70's. Within the last year she has been told that this drug has caused her heart's ejection factor to be pumping half of its normal rate. She is now taking Coreg and Lisinopril. For many years she has walked a couple of miles each morning and eats properly..(Her husband is a retired cardiologist.) Have there been any studies on Adriomycin that would be helpful for her or her husband to know about? If possible, I would like Dr. Taylor's opinion on this and any research. Speaker_-_Dr__David_Taylor : Adriamycin can cause cardiac damage and lead to cardiomyopathy and congestive heart failure, even many years after the treatment. Once the heart failure has developed the treatment is the same as other forms of heart failure and cardiomyopathy, including beta-blocking agents, ACE inhibitors, diuretics (fluid pills), occasionally digoxin and aldactone or eplerinone. Salt restriction and low-level exercise are also recommended. There is nothing unique, research-wise or therapy-wise, about adriamycin-induced cardiomyopathy that would benefit this patient at this stage. More information about Heart Failure can be found on the Cleveland Clinic website. LVAD and Heart Transplant additional questions pack7-0: My cousin had a transplant a couple years ago. Now his new heart is having problems and he is in heart failure. Why would that happen? Speaker_-_Dr__David_Taylor: If a transplant patient has heart failure again it is most likely do to rejection of the new heart. Unfortunately, even with our current anti-rejection medicines, rejection episodes still occur. truckerron: I am a congestive heart failure patient Can you tell me more about the LVAD? When do they decide someone should have an LVAD device? I saw a tv show and the doctor talked about this device and I want to know more. Speaker_-_Dr__David_Taylor: Please see our website - http://www.clevelandclinic.org/heart - go to Heart Guide and click on Heart Failure. There is information on the LVAD device. Other heart questions marper: If you had electric shock treatment for a mild Afib, no pacemaker, and all seems to go fine - do you still need to take coumadin? Speaker_-_Dr__David_Taylor: That depends on many factors including the duration of the atrial fibrillation and other risk factors for blood clot formation and subsequent stroke. Occasionally patients with rare episodes of atrial fibrillation may not require long term coumadin. One would need to review the cardiac status and the risk factors with their doctor in detail prior to this difficult decision. smithvolt3: You are my Doctor for Congestive Heart Failure. The treatment I have received from you has been extraordinary. I have been in Atrium Fibrillation for over 7 years with 3 tries at Cardioversion that didn't work. On my last ICD event my heart went into sinus rhythm and has been in sinus rhythm for 4 months now. What is the chance that long term changes in my heart have allowed that to occur whereas it did not ever occur prior to four months ago. I would imagine that the drug regiment you have me on also had a lot to do with me getting kicked into sinus rhythm? Speaker_-_Dr__David_Taylor: Thank you for those kind words. Your case is somewhat unusual in that most patients with chronic atrial fibrillation, particularly those with heart failure, have difficulty maintaining a normal sinus rhythm. However, we occasionally see patients such as yourself who after improvement in their heart failure syndrome, can maintain sinus rhythm. You are correct that the combination of medications which led to the improvement in your heart failure syndrome are responsible for the ability to stay in sinus rhythm after all those years of atrial fibrillation. geoswife43: If you have both atrial fibrillation and mitral valve prolapse, can they lead to heart failure? Also asked: If atrial fibrillation and mitral valve prolapse can lead to heart failure, what tests should be done to prevent that? Can one condition be a symptom of the other? Speaker_-_Dr__David_Taylor: Poorly controlled atrial fibrillation can occasionally lead to heart failure. Mitral valve prolapse when associated with severe mitral valve leakage or regurgitation, can also lead to heart failure. Speaker_-_Dr__David_Taylor: Luckily, this is uncommon. Cardiac ultrasound or echocardiography is often the best test to monitor for the potential development of worsening cardiac function and the risk of heart failure. Mitral valve prolapse and regurgitation can cause atrial fibrillation - but atrial fibrillation does not cause mitral valve prolapse. Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Taylor is over. Thank you again for taking the time to answer our questions today. Speaker_-_Dr__David_Taylor: Your welcome. Thank you for having me. More information:
Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC). © Copyright 2008 The Cleveland Clinic Foundation. All rights reserved 4/08 |
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