"Congestive Heart Failure" Tuesday, November 30, 2010 Roy Small, MD Cardiologist Lancaster General Health Heart Center Paul Casale, MD Cardiologist Lancaster General Health Heart Center
11-30-2010 Congestive Heart Failure Tuesday, November 30, 2010 6:56
LG Health Admin: Hello and welcome to our Congestive Heart Failure Q&A with Dr. Paul Casale and Dr. Roy Small. The session will begin in a few minutes.
6:58
LG Health Admin: Dr. Roy Small is an interventional cardiologist with The Heart Group in Lancaster, PA. He runs the Heart Failure Program at Lancaster General Health and leads the Heart Failure Clinic at The Heart Group.
6:58
LG Health Admin: Dr. Paul Casale is an interventional cardiologist with The Heart Group in Lancaster, PA. He is Chief of Cardiology and Medical Director of Quality at Lancaster General Hospital.
7:00
LG Health Admin: Thank you for joining us for today's Q&A session. We encourage you to begin asking your congestive heart failure questions now, as we have already received several excellent questions that Dr. Casale and Dr. Small are answering for you.
7:01
[Comment From Stefania ] As a patient on hemodialysis for 8 years.....not diabetic.....otherwise healthy......is congestive heart failure in my future? I am 66 years old and waiting for a transplant in 2012....5 years after renal cancer (right kidney removed).
7:02
Dr. Paul Casale: Not necessarily, but high blood pressure is often a problem for patients on hemodialysis and high blood pressure is one of the strongest risk factors for the development of congestive heart failure.
7:02
Dr. Paul Casale: Therefore, it is important for your blood pressure to be well controlled.
7:05
[Comment From Ed ] Can Ca. Sup. increase potential for blood clot or heart attack? Supplements to help reduce leg cramps. I take: ABC SR. + One a Day, which has 200mg CA, 10mg Mg, 15mg ZN, and 2 Chleated 666mg Ca, 260mg Mg, 17mg Zn;+ 1 oyster 500mg Ca. a tot of 1200mg Ca, 360mg Mg, and 32mg Zn per day. I spread the dosage over Morning, Dinner, and night. I swim 1 mile in 36 minutes 3X per week. no have leg cramps. Is there any potential problem? (I take low-dose aspirin, Plavix, Crestor, Zetia, Metorolol)
7:05
Dr. Paul Casale: There was a recent study that found an increased risk of a heart attack in people taking calcium supplements. Most were women who were taking calcium supplements to treat osteoporosis.
7:05
Dr. Paul Casale: This study did not include those who were taking Vitamin D along with the calcium supplements. More research is needed before concluding that calcium supplements increase the risk of a heart attack.
7:05
[Comment From Nelson, NJ ] I have had triple bypass 9 years and doing well. However, I had a bout of A-FIB 2 months ago and am on Maltaq. Is there a progression of heart diease to CHF?
7:05
Dr. Small: Not necessarily. Careful control of risk factors can slow or minimize progression of coronary disease for long periods of time. Heart failure may sometimes develop in patients with coronary disease. A-Fib does not necessarily indicate progression of disease.
7:06
[Comment From yvonne ] my mother feels like somebody is holding her nostrils closed and somebody is putting their hands around her throat when she stands or walks, why is that?
7:06
Dr. Small: It is impossible to answer with the given information. Your mother should be seen and evaluated and this will include a physical exam and some simple testing such as a chest xray and blood tests.
7:08
[Comment From Earla ] I have Congestive Heart Failure since 2005, with a pace maker & defib device. I have had one experience of my machine going off what's the best way to be sure this doesn't happen again?
7:09
Dr. Paul Casale: It is important to have your pacemaker and defibrillator checked on a regular basis. A shock from the difibrillator is usually in response to a irregular heart rhythm.
7:09
Dr. Paul Casale: I would recommend that you would talk with your cardiologist about your concern.
7:09
[Comment From Nelson, NJ ] What is the primary/major symptom of CHF? I heard that swelling around the ankle is one of them.
7:10
Dr. Small: The primary symptoms are related to fluid retention. So, swelling around the ankles, swelling of the belly, weight gain and shortness of breath are the most common symptoms.
7:10
Would you describe the dinner you had this evening as "heart healthy"? Yes ( 53% ) No ( 40% ) I haven't eaten dinner yet ( 7% )
7:11
[Comment From Bill ] How much "diagnostic faith" do you have in stress tests? I, on two occasions, have gone through a bank of three stress tests trying to determine if a problem - one led to another. Final conclusion? No problem found. As a result, I determined that since I exercise regularly and am on treadmills 3 times per week, I will monitor my body as opposed to scheduling another stress test.
7:12
Dr. Paul Casale: A stress test is very useful in determining if someone has underlying coronary artery disease. There are different types of stress tests, often combining EKG monitoring with ultrasound or a nuclear imaging of the heart.
7:12
Dr. Paul Casale: Sometimes the results of a stress test are indeterminate and other imaging modalities of the heart are recommended.
7:15
[Comment From Nelson, NJ ] Are there different stages of CHF? For example, can you take medicine versus having a pacemaker or other device?
7:15
Dr. Small: Yes. There is actually a very formal staging process. The intensity of treatment increases as the disease progresses. So medicines are appropriate depending on the specific cause of heart failure and sometimes devices (pacemakers and defibrillators).
7:15
Dr. Small: Both these medicines and devices need to be customized to the individual patient depending on the specifics of their disease.
7:17
[Comment From Arlene ] What are the beginning heart symptons that lead to CHF and what can be done to avoid it?
7:17
Dr. Paul Casale: Thanks for the question Arlene. Shortness of breath, or ankle swelling are often signs of congestive heart failure. A way to avoid congestive heart failure is to keep your heart healthy.
7:17
Dr. Paul Casale: Exercise, maintenance of appropriate weight, not smoking, will help to keep your heart healthy.
7:17
Dr. Paul Casale: Other risk factors for the development of coronary artery disease include high-blood pressure, high-cholesterol, and diabetes.
7:18
How many of you have ever had a stress test? Yes, I have ( 69% ) No, I have not ( 31% )
7:19
[Comment From sheila ] Once diagnosed, what is the after life expectancy of someone with CHF?
7:19
Dr. Small: It depends upon the specific cause of heart failure and the associated conditions. If treated appropriately with medications, diet, and lifestyle changes, the prognosis may be excellent.
7:19
Dr. Small: On the other hand, untreated patients with heart failure do poorly. Once admitted to the hospital with heart failure the mortality is 50% in five years in patients who are NOT TREATED according to current standards.
7:20
[Comment From Nancy ] What are your thoughts about low dose aspirin taken by a 68 year old woman--I've read so much conflicting comments about its efficacy?
7:20
Dr. Paul Casale: There continues to be controversy regarding the use of aspirin for the primary prevention of heart attack, particularly in women, as they appear to be at a higher risk for bleeding with aspirin.
7:21
Dr. Paul Casale: I would recommend that you talk with your family physician since the decision to take aspirin for primary prevention will depend on your risk factors for the development of coronary artery disease.
7:26
Do you take aspirin regularly for your heart health? Yes ( 67% ) No ( 33% )
7:26
[Comment From Karen ] My dad has a narrowing of the subclavial artery. He has had bypass, and valve replacement in years past, and recently had a stent put in. Nothing has been done to the subclavial artery. He continues to have shortness of breath and has been diagnosed with chf. Should the subclavial artery be opened for better breathing results?
7:26
Dr. Paul Casale: I do not have enough information to give you advice regarding your father's subclavian artery narrowing. There is a clinical situation in which blood flow from a left internal mammary artery bypass graft to the heart is reduced by a severe narrowing of the left subclavian artery.
7:26
Dr. Paul Casale: Depending on the clinical situation, opening the left subclavian artery can be of benefit. I would recommend that you speak with his doctors for specific advice regarding your father.
7:26
[Comment From Guest ] My biggest concern is that i will lead to CHF. I work out (rumbent bike and treadmill) 3 times a week and lift weights. I am 56. Is CHF the loss of blood flow to fuel the heart muscle? Can a person have another bypass to avert the progression of CHF?
7:27
Dr. Small: Heart failure is a syndrom which is a result of the heart being unable to supply adequate blood to the body. There are many different cause of which coronary disease is one. But coronary disease doesn't necessarily lead to heart failure.
7:27
Dr. Small: The best way to prevent heart failure is proper diet, regular exercise, and treatment of the diseases known to lead to heart failure (diabetes, hypertension, coronary artery disease, etc.). Toxins such as cigarettes should be avoided and alcohol minimized.
7:27
[Comment From Bob Butler ] I had an ICD implanted recently. Are there any recomended sleep positions?
7:28
Dr. Paul Casale: There are no specific recommendations regarding sleep positions after ICD implantation.
7:30
[Comment From George ] If you have a swollen foot, newly appearing red sores on the foot, foot sweating and difficulty breathing at times and a history of high blood pressure is that evidence of CHF
7:30
Dr. Paul Casale: I do not have enough information to answer your specific question. In general, congestive heart failure causes swelling of both feet rather than just one foot.
7:31
Dr. Paul Casale: Shortness of breath can be a sign of congestive heart failure or may be a sign of a pulmonary problem.
7:31
Dr. Paul Casale: High blood pressure is a risk factor for the development of congestive heart failure. I would recommend that you see your family doctor for evaluation.
7:31
[Comment From sheila ] What are the latest and future hopes for treatment of CHF, and are all treatment options available through the Heart Group and Lancaster General?
7:32
Dr. Small: There are new drugs and devices constantly being developed. Here at the Heart Group we participate in more than 20 clinical trials evaluating these different drugs and devices.
7:32
Dr. Small: The only option that the Heart Group does not offer is heart transplant for patients with advanced disease. We work closely with transplant centers for those patients who need this intervention.
7:32
Dr. Small: One of the newer approved treatments for patients with advanced heart failure is an implanted permanent ventricular assist device (VAD), which we offer here at LGH.
7:33
[Comment From EK] I had an echocardiagram about 3 months ago. I have Sarcoid. The echo was normal but interventric septum & posterior are increased in thickness & moderate concentric LVH identified w/ left ventricle chamber size normal. Mild posterior mitral annular calcification seen. I am a 53 year old female, overweight & inactive. Do I need to be concerned? Family doctor did not refer me to a heart doctor at this time.
7:34
Dr. Paul Casale: There are many causes of left ventricular hypertrophy (thickening of the heart muscle); high blood pressure is one of the most common causes.
7:34
Dr. Paul Casale: I would recommend that you talk with your family doctor about your concerns and your question regarding a consultation with a cardiologist.
7:35
[Comment From Guest ] I have heard that heart failure is a disease that effects older folks is that true and how do I prevent this disease?
7:36
Dr. Paul Casale: Congestive heart failure occurs more frequently in the elderly. Since congestive heart failure is often due to coronary artery disease, prevention of coronary artery disease by not smoking, maintaining an appropriate weight and exercising on a daily basis are important.
7:36
Dr. Paul Casale: Other risk factors for coronary artery disease include high blood pressure, diabetes and high cholesterol.
7:38
Do you take medication for high blood pressure or high cholesterol? Yes, for High Blood Pressure ( 18% ) Yes, for High Cholesterol ( 18% ) Yes, for Both ( 36% ) No ( 27% )
7:39
[Comment From sheila ] I've heard that CHF is a big reason for hospital admissions and readmissions. When you consider all the disease and conditions out there, where does CHF fall in terms of cause for concern and the number of people affected?
7:39
Dr. Small: That's true. Heart failure is one of the most common reasons to be admitted to the hospital for patients over the age of 65. It's a very expensive condition to treat in part because of frequent re-admissions.
7:39
Dr. Small: It's the number 1 expense to medicare and it's over 25 billion dollars a year. LGH has one of the lowest re-admission rates for heart failure in the state of PA.
7:40
[Comment From Joan Eberly ] I recently saw a woman on TV who was having the cholesterol being removed from her blood. Is this going to be a help offered to those who cannot take statins?
7:40
Dr. Paul Casale: Removing cholesterol from the blood, which is called lipid apheresis is a specific treatment for patients with familial hypercholesterolemia, in which maximal medical therapy, and diet, has been ineffective, or not tolerated.
7:41
[Comment From sheila ] Some of the risk factors you note are clearly something that may have been building for a while/a lifetime? If you're 65 with high blood pressure or overweight, etc., do you still have time to make things better with lifestyle changes?
7:42
Dr. Small: Absolutely. Those interventions are alway appropriate. While not all diseases can be reversed (many can be, such as diabetes with weight loss), the progression of the disease can always be effected.
7:43
[Comment From Shelley ] My dad is 83 and had bypass surgery last year. He has pacemaker, defib, was in the hospital recently and had 650 ml drained from his lung. At that time he had no symptoms. Now he has chest congestion, shortness of breath, extreme fatigue. His lasix was increased to 80 mg twice a day. They had increased his toporol, but decreased it today as his fatigue has become overwhelming. Any thoughts??
7:44
Dr. Small: It sounds like he has fairly advanced disease. I can't make specific disease management recommendations without more information. He should be seeing a heart failure specialist.
7:46
[Comment From Bill ] I have been diagnosed with coronary artery disease and sleep apnea. What are your thoughts on treatment to prevent CHF?
7:46
Dr. Paul Casale: In patients with coronary artery disease, one of the goals is to prevent progression of the severity of coronary artery blockages which may lead to the development of congestive heart failure.
7:46
Dr. Paul Casale: Risk factor modification, which includes lowering cholesterol, blood pressure and diabetes control (if indicated), along with therapeutic lifestyle modification (diet, exercise, not smoking), are important in the treatment of coronary disease.
7:47
[Comment From sheila ] Interesting note on your low readmission rate. What is there about how you approach or treat CHF that accounts for that?
7:47
Dr. Small: We have a very well organized inpatient heart failure program and outpatient heart failure clinic. We are leaders in the use of devices to monitor patients remotely. We have a dedicated staff of nurse practitioners, nurses and technicians, who are devoted to the care of these patients.
7:48
Are you a member of our Heart Healthy Support Group at Lancaster General Health? Yes ( 18% ) No ( 82% )
7:49
[Comment From Donna ] Other than maintaining a healthy weight, appropriate diet and regular exercise, what other suggestions do you have for a patient who cannnot tolerate statins to help with lowering the LDL level?
7:49
Dr. Paul Casale: There are other classes of medications for lowering LDL cholesterol other than statins. Some of these include fibrates, niacin, and certain medications that interfere with the absortion of cholesterol from the intestines.
7:50
Dr. Paul Casale: I would suggest that you talk with your family physician to determine if one of these options are appropriate for you.
7:50
[Comment From Joan ] I have a Taxus stent and was told to take Plavix the rest of my life. Now the doctor says stop taking Plavix. With a differene of opinion who do I believe?
7:50
Dr. Small: We know that patients with a drug eluding stent (of which Taxus is one type) should absolutely take asprin and Plavix for at least a year. Beyond that, the data is less clear and there might be a legitimate difference of opinion.
7:51
[Comment From Guest ] My mother was recently diagnosed with heart failure and a weak heart. What does this mean and what are the treatments for this problem?
7:51
Dr. Paul Casale: Congestive heart failure is often due to a weakening of the heart muscle. When the heart is weak, it is unable to pump as vigorously as a normal heart and can lead to fluid buildup in the body causing shortness of breath and swelling in the lower extremities. Treatment of a weak heart depends on the cause.
7:52
Dr. Paul Casale: If it is due to blockages in the coronary arteries, sometimes opening the blockages with stents of bypassing the blockages with surgery can be effective. There are several types of medications that can help patients with congestive heart failure.
7:52
Dr. Paul Casale: These include beta-blockers, angiotensin-receptor blockers, and diuretics. Sometimes a special type of pacemaker can be an effective treatment.
7:54
[Comment From Roy ] Why are stress tests unreliable? I had two that showed I had major blockage. Dr. Small did 2 heart caths and I was open. A friend of mine had a stress test and passed it, but a week later had a heart attack.
7:54
Dr. Paul Casale: Stress tests are very good at assessing the presence of coronary artery disease, but they are not 100% accurate.
7:54
Dr. Paul Casale: There is a percentage of false positive tests that can lead to a recommendation for a cardiac catheterization for further clarification.
7:55
[Comment From sheila ] How active can a person with CHF be? I realize probably can't play 18 holes of golf with advanced heart failure, but is some level of activity still OK in earlier stages?
7:55
Dr. Small: Yes, absolutely. Exercise is a good thing for patients with heart failure. In general, exercise is symptom limited. Most patients with early disease have a normal functional capacity. Lots of my patients can play 18 holes of golf.
7:57
LG Health Admin: JUST A QUICK REMINDER! Please take a moment to fill out our brief survey and let us know what you thought of this session and ideas you may have for future Q&As. We'd love to hear what you think! http://bit.ly/QA_Survey
7:57
[Comment From George ] Are either of you accepting new patiences at The Heart Group ??
7:57
Dr. Paul Casale: Yes.
7:57 7:57
Dr. Paul Casale: Thanks for participating.
7:58
Dr. Small: Thank you for your questions. We hope this has been helpful.
7:58
LG Health Admin: If you have more questions that you would like Dr. Casale and Dr. Small to answer, please feel free to use our question form, and we will make sure that the doctors receive it, and future responses can be posted in our archives for this session, or in a future "Cardiology Corner" blog posting.
7:59
