Transcript of live chat with heart failure expert, Jonathan Sackner-Bernstein
February 13, 2001, 9:00 PM ET
DrRich: I am pleased to welcome to our chat tonight Jonathan Sackner-Bernstein, MD, a noted expert on heart failure. Dr. Sackner-Bernstein is the Associate Chief of Cardiology and the Director of the Heart Failure Program at St. Luke’s-Roosevelt Hospital Center in New York.
I will commandeer the host's preogative and ask the first question. Dr. Sackner-Bernstein,
what is the purpose of heart failure awareness week?
Dr. Sackner-Bernstein: Heart failure is a syndrome that is responsible for major disability, and is associated with a high risk of
hospitalizations and death. Unfortunately, the people most affected are elderly (and those over 65) and many times,
the symptoms of heart filaure are blamed on aging. This is a problem because there are
treatments that can markedly improve quality of life and lower the risk of death. Heart failure awareness week exists to raise awareness for both
coralee: I wanted to know if there were any new treatments for dilated cardiomyopathy?
Dr. Sackner-Bernstein: Dilated cardiomyopathy is treated as is congestive heart failure that is associated with a weak heart. For such cases, the treatment strategies start with the use of diuretics (water
pills) as needed to treat salt and water retention. Then the important medicines are introduced, ACE inhibitors and beta-blockers. These two medicines make people feel better and live longer. there should be a very clear reason why
a person with heart failure who has a weak heart is not on both these medicines, and there are some cases, but for the most part, these medicines, ACE inhibitors and beta-blockers, are standard treatments.
In fact, anyone who has a history of a heart attack, diabetes or high blood pressure who realizes that they cannot do the same activities they could in the past
should ask their doctor to be tested for heart failure. The two most common symptoms are shortness of breath or fatigue, and either may be
associated with swelling in the ankles.
ray: If you're in heart failure is it recommended to take cardizem and lasix? Also, what are the latest beta blockers?
Dr. Sackner-Bernstein: First of all, realize that the most common kind of
heart failure is when the heart muscle is weak. I will speak to this situation. In such cases, lasix is used for fluid retention, generally at a higher dose to get rid of the
swelling, then a lower one to keep it from coming back. That dose can be reduced as sodium intake is reduced. Cardizem is a calcium channel blocker, for which there is no study that
supports it being used for patients with weak heart muscles. Of course, there are always exceptions, so you should talk to your doctor. But, a patient
with heart failure needs to know why they are not on an ACE inhibitor and a Beta-blocker.
Wally: I am a 57 yr old male, diabetic, insulin dependent. I have been diagnosed by heart cath as having heart damage, functioning at EF20%. Was informed only treatment was
medication. When I asked specific question about prognosis and progression, my Dr. would only reply that You have a very very weak heart. The cause of the damage is yet to be determined. I need to know what options I have, or what treatment would be available and any other advice you can give to me. I am
With heart function at 20% what is the prognosis?
Dr. Sackner-Bernstein: The truth is that your prognosis would be based on your condition once you have already received optimal medicine. In a case such as yours, you should be treated with diuretics, digoxin, ACE inhibitors and beta-blockers. These medicines would be introduced over several weeks, and then given a chance to work. In general, I try to wait at
least 3 months after starting treatment before assessing the patient's condition. However, if you did not feel better (and
respond by other tests) then one would need to be very aggressive in such a young person. The issue of revascularization (angioplasty or bypass) would need to be considered early, and if that wasn't an option, and you were not responding to medication, you may be forced into
considering a transplant. This may seem radical, but for the right person, this is a tremendous option that can restore your life towards normal.
RobL: Can you tell me roughly how many cases of coronary artery disease end in death? and what roughly % end in recovery? and what the MOST important
issues are for both results?
Dr. Sackner-Bernstein: This is a difficult question, because it is broad. Let me assume that you have heart failure caused by coronary artery disease.
Realize that neither coronary artery disease or congestive heart failure are ever completely cured. However, the risk of death from heart failure in general is reported to be as high as 50% within 3 years. Sounds horrible when you consider that a person who is a healthy 65 year old will likely live until 80. However, it is not as bad as this, because those depressing
statistics are for people with heart failure before ACE inhibitors and beta-blockers were known to be effective. Each one reduces the risk of death by 35-40%, so the
future is actually a lot better than most of the textbooks make it sound.
Daisy: Can you please explain the difference between "good" cholesterol and "bad" cholesterol -- what prevents or contributes to heart failure. my daughter tries to explain this to me... says
I should watch one and stock up on another but I don't understand the distinction.
Dr. Sackner-Bernstein: Abnormal cholesterol, called dyslipidemia by cardiologists, is a factor that commonly leads to heart
failure, usually by causing heart attacks that damage the heart. if you have abnormal cholesterol, that would mean the bad (LDL) is high and the good (HDL) is low.
Medications called statins markedly reduce the LDL cholesterol and reduce the risk of heart attacks and heart failure, and keep you alive. If you have coronary artery disease, this number should be low according to the guidelines, and many people believe it should be very low, even less than 100 for the LDL.
Hensylee: How does COPD figure in with heart failure? Have a male friend with COPD - HE'S 68
Dr. Sackner-Bernstein: Having COPD, chronic lung disease such as emphysema or chronic bronchitis, can make the treatment of
heart failure more difficult. This is because the symptoms of COPD and heart
failure are often similar, so it can be difficult to know which medicine to adjust. Also, if a person has
significant COPD, they should not be given a beta-blocker, because it can worsen COPD. There are people I have treated who have COPD who I have successfully treated with beta-blockers, but this is a higher risk
situation, and should only be done by a doctor with a lot of experience with this combination.
maxi: With the new medicines available to treat cardiomyopathy, is the outlook better?
Dr. Sackner-Bernstein: Much better. As I stated a few minutes ago, the risk of dying is reduced by around 35% by
using ACE inhibitors, and another 35% by adding beta-blockers. There are also benefits on who people feel with these medicines.
spring: Can a person with a pacemaker implanted experience an increase in EF when the programming to the pacemaker is changed. Would this be viewed as encouraging?
Dr. Sackner-Bernstein: If a standard pacemaker were implanted into someone with
heart failure, I would be dubious that the pacemaker was responsible for the increase in ejection fraction.
However, I do not want to"rain on your parade" as an increase in ejection fraction is generally a good sign. SO even if I don't believe it is the pacemaker, the news is still good.
PTB: If you are diabetic, are you can you still be a candidate for transplant and would you not be put very low on the list?
Dr. Sackner-Bernstein: Yes diabetics can be candidates for transplant, and can do well.
In general, diabetics need to be free of significant "end-organ" damage though, meaning good kidney function, no major disease of
peripheral arteries, and hopefully not much retinal disease. This can be explored during a visit at a transplant center.
Herb: What are the prospects for heart replacements like ABIOCOR?
Dr. Sackner-Bernstein: The pace of investigation for devices to support or replace heart function has been incredible. The Abiocor is a totally implantable artificial heart that is entering clinical trials. Many believe that such devices
will eventually be better options than transplant, and more readily available. For now, the device that are most likely to be used widely would be special pacemakers called biventricular pacemakers, which are also experimental but further along in the process of
investigation. So we will know about them sooner.
jd: What gives the best information a UltraFast CT electronic beam scan or a lung
CT with a lung x-ray
Dr. Sackner-Bernstein: I think that in many cases, a careful review of a patient's condition and family
history can tell more than either of these tests. However, between the choices you gave me, the ultrafast CT is recognized as offering better resolution, meaning it would be superior.
Dot: Can you comment on the new blood test for CHF?
Dr. Sackner-Bernstein: The blood test you are referring to is one that measure BNP, a hormone that your body (actually the heart) makes when you have CHF. It works, but I believe there is more hype here than substance. I doubt it would be as good as a careful assessment by a doctor For the
diagnosis of heart failure. Also, once that test is positive, you still would need an echocardiogram to find out if your heart failure is the common type, with a weak heart or a the less common form, a still heart, because the treatments are different. I would propose a different strategy. If you have had a heart attack, have diabetes or high blood pressure, and have either shortness of breath when you walk around, get tired more than you used to, or have ankle swelling, get an echocardiogram.
Hensylee: Can/does atrial fib lead to heart failure ?
Dr. Sackner-Bernstein: If you have atrial fibrillation with a very fast heart rate for months and years, your heart will get weak and heart
failure will develop. Some believe that having atrial fibrillation makes you sicker with
your heart failure, but this hasn't been proven.
Wally: At what EF % would a heart transplant be indicated?
Dr. Sackner-Bernstein: The ejection fraction may not be as important in all cases as how sick you are, although a cutoff is usually 35% or less. The Issue that should make transplant a consideration is how sick you are. If you are very limited, get yourself to a transplant center for a
consultation to decide whether transplant should be considered, and whether in the short term or long term.
Lady: What are the long term effects of Tambocor?
Dr. Sackner-Bernstein: This is a medicine used to treat specific arrhythmias, and not to treat heart failure specifically. In terms of medicines used to treat arrhythmias, we learned long ago that, in general, antiarrhythmics can do more harm then good. However, I care for several patients who are taking such drugs and doing well, so don't stop yours. Ask your doctor why you are receiving it as opposed to considering an ICD. ICD's are implantable defibrillators, and many who would need such medications could benefit from an ICD even more.
Again, that is the case for most patients, not all, so discuss this issue with your doctor. If you
don't feel comfortable with the doctor's response, go ask another to make sure you are treated optimally.
luna: Can a person benefit from exercise if she has a ejection fraction of 44%. even if she is on beta blockers and ace inhibitors?
Dr. Sackner-Bernstein: Definitely, exercise is good - but it has to be the right kind of exercise. Gradually increasing aerobic
activities is ideal, until after several or many weeks, you can exercise for 20-30 minutes at a time. Talk to your doctor about specific recommendations, but know to avoid heavy lifting, and use common sense. If you have trouble talking while exercising, you should slow down.
momx2x1: What are the chances of a 38 year old woman with a heart attack
3 weeks ago of having another?
Dr. Sackner-Bernstein: You want to figure out what her risk factors are
for progression of coronary artery disease, and treat any risk factors aggressively, and not tolerate a laisse faire attitude.
She should be receiving four medication - ACE inhibitors, beta-blokcers, statins and
aspirin - unless there are very good reasons not to. Make sure the LDL- cholesterol is below 100, and of course,
she should not smoke. She should get an exercise prescription from her doctor and
specific instructions regarding her diet.
DrRich: Last question. How can a patient with heart failure tell if he/she is getting optimal therapy?
Dr. Sackner-Bernstein: First, start with a review of self care advice you have been given. If your doctor has not reviewed specifically how to keep to a low salt diet, you are not receiving optimal care for a simple target. You should be told to weigh yourself everyday, and to call
if your weight goes up (usually 2-3 pounds in 2-3 days is a guide that is used). Then move to medicines.
On an ACE inhibitor and a beta-blocker? If not , there is potential trouble in your doctor's approach (except in clearly defined exceptions). Next you could look at the doses of medicines. Is the maximally tolerated dose being prescribed? Make sure your doctor is treating your cholesterol and diabetes aggressively, if your are affected by these problems. Now, what do you do if the score is not favorable? Ask to see a specialist, a
cardiologist focused on heart failure or a transplant cardiologist. Usually doctors involved in clinical trials are more on top of these issues than
a generalist can be, just as you wouldn't necessarily ask a transplant cardiologist about cancer screening.
DrRich: So heart failure is a condition where the competence of your
doctor can make a huge difference?
Dr. Sackner-Bernstein: Absolutely.
DrRich: I think we're about out of time. I want to thank our heart failure expert, Jonathan Sackner-Bernstein, MD, for his participation in this rapid-fire session.
Jonathan, you did a great job. Thanks very much.
Dr. Sackner-Bernstein: Thank you for the opportunity to share my thoughts.
Articles related to topics that came up in this chat:
Cardiomyopathy and heart failure
Beta blockers in heart failure
Cholesterol and triglycerides
Ultrafast CT scans
What do you think? Enter the Heart Disease Forum:
