Chapters Transcript Video Seventh Annual Clinical Advances in Heart Failure and Arrhythmias: Case Presentations and Panel Discussion - Part 1 Drs. Heywood, Srivastava and Mohan review real-life cases from their practice and answer questions from course participants (session 1 of 2). Back to Symposium Page » So here's a 56 year old woman with the history of hepatitis C with cirrhosis. Event referred for evaluation. Um, she was seen by primary care for shortness of breath and had several months of progressive dysthymia with exertion had previously been treated for hep C and had cleared. This, although had still developed cirrhosis, just part of her shortness of breath evaluation by our primary care. She had a CT angiogram to rule out pulmonary embolism, which was negative. And then an echo which showed RV enlargement high, r p a pressures. And so it was then referred to cardiology. So again, you know, looking at the echo is part of that initial diagnostic measure for shortness of breath in this patient certainly revealed some abnormality, so the echo pressures were significantly elevated. Peer pressure of 75 uh, in a mean of 45. So here's what her echo looked like. So you can see here, you know, significant RV enlargement, right? Atrial enlargement. Some of the things we talked about before the left this intra ventricular septum, sort of going over towards the left. Same with the inter atrial septum. Smaller left atrium. So all of this sort of fits with, you know, the suspicion that she may have pulmonary arterial hypertension, other views of her echocardiogram here. So that d shape septum. Where, um, because of the RV pressure overload, the septum kind of gets flattened during sisterly and during the athlete. And sometimes during sisterly when the pressure is significantly elevated, you can see that there on the left side of the screen. And with key is this right? Uh, slide is the mitral inflow. So this is looking This is part of our evaluation for left sided filling pressures. Diastolic gee, and this looks essentially normal. So this the echo alone, particularly with her history of cirrhosis, eyes very suggestive of pulmonary arterial hypertension. So because of this, she gets the right heart catheterization. And, um uh, this sort of confirms what we were suspecting. Right? Atrial pressure of eight. Pay pressure of 79/33 with a wedge pressure of 13. So right there, we've made the diagnosis of Pullman arterial hypertension. Cardiac output is low 3.4 index of 1.7. So her palm a basket resistance is quite high. It's 10.5 woods unit. So This is somebody who's high risk, who has significant disease, which we think is related. Thio her liver disease and hep C. And so it started on combination therapy. We again said, you know, low to moderate risk in class two or class three symptoms. You know, if they're low risk, we considered monotherapy. If they're higher, moderate or higher risk, we would consider a combo therapy and even potentially i v therapy. So she was initially started on a combination of Orel therapy. Given that she was functional. Class three, she was started on to Dalla fill in massive 10 10 and seeing pretty regularly in clinic. And she actually had a pretty dramatic improvement in her symptoms. She went from essentially class four to class to over several months, and there was planned for a repeat right heart catheterization, uh, in a coming months. So in the meantime, though, she had a repeat echo, and you can see now her echo. Her most more recent echo is on the left side. Can you guys see that? Okay, um, or echo is on the left side. Uh, it's looking like a blue screen. Can you Can you see that Oh, good. Okay, um whereas the original one that I showed you is on the right side so you can see that the right ventricle looks better. Um, smaller size there. And here is the long sort of the four chamber view. Significant improvement already in her right ventricular function. Right? Ventricular size. Right atrium. So little dilated, but starting to look more like a normal eco compared to the one on the right side of the screen. So this is with just the combo Orel therapy that she got. It really is a testament to the fact that we can really reduce pressures and improve functional class when we get therapy started, uh, earlier in these patients with significant palmer hypertension. Hey, Raj, can I ask you a quick question? Sure. Every now and then, it's not common. But every now and then we see a patient who, where there is transferred from out of state and they come on a certain regiment and they don't recollect having a right heart cat on. Do you know, sometimes they've been started on therapy regimen because the echocardiogram looks like this, You know, How do you approach? Let's say this patient came to you with this echo on some therapy. But you don't have documentation of a right heart cat or you're not sure. How do you go about patients? Yeah, that's a good question. I mean, you know, it depends on their kind of history. If they've got significant risk factors, you know, they've got over cirrhosis. If you've got some sort of connective tissue disease that lends itself to the diagnosis of group one Pullman hypertension, then you know we may continue that therapy, but But they all need to right heart catheterization. So if we have somebody that we that we haven't seen before, that's on this type of treatment that's never had a right heart catheterization. Um, then we will still move forward with doing the right heart catheterization, seeing what their pressures, air like. You may still get some clues. You can do that on therapy and just see if there's, you know, their PBRs may not be normal. They might be better than what presumably they were before, but they still all deserve a right heart catheterization to ensure that we're treating the right thing. Because there have been times where people patients have come who have had maybe not such overt findings like this Echo shows but just elevated pulmonary pressures. Who've been on directed a pulmonary anti hypertensive. And then, when we do a right heart catheterization, it's more clear that they have left sided heart disease or wedge pressure. They're elevated, and so their treatment strategy changes pretty significantly. But yeah, I think it is important that all these patients, they have not had a right heart catheterization. Or if it's been a long time since they've had to write her capitalization, it's worth doing another cap to see kind of where things are. Thank you. Yeah, that's been my practice as well. You know, I think if I don't have a right heart cat as conclusive as it looks, I've generally founded every now and then it you could be thrown off, and it almost is good practice to have a baseline right hard cat to work with, right? Absolutely. Yeah. Her case was unfortunate. Complicated. Her liver disease started to get worse. And, you know, about nine months later she was admitted to another hospital with Human TEM. Assist had to have a tips on after the tips. Her Pullman pressures actually got worse again. Bedside Echo and clinic showed her pressure's back up to 70. We did a repeat calf, and her pressures were significantly elevated. So she was admitted and started on I d therapy and ultimately consideration for a liver transplant once or pressures were improved. You know, I could make one comment to you know, if patients have liver disease and pulmonary hypertension, unless the pulmonary hypertension is controlled them. They're not candidates for liver transplant. But if you can control them, they are candidates. And we've had a number of people undergo successful liver transplant as we're treating their pulmonary hypertension, and then they're pulmonary Hypertension tends to get much better, so it's really gratifying thing that you can actually reversal. They can undergo a liver transplant, but they need really need to be aggressive with their control of TA pressures so that they could go under, undergo the treatment safely, transplants safer so that that's the case in terms of palming pressures that I wanted to share with you all. You know, we've got a lot of patients enrolled in our studies, um, gotten interracial shunt devices, and it would be nice to highlight the changes in human dynamics and those patients. But the tough part is is that we're blinded, um, in terms of whether or not those patients got shunt devices or not. So I can't really present a lot of those cases here as of yet, maybe by in the next couple of years. You know, as we started blinding people will have more data to be able to share. How, how, what we've seen in terms of human dynamic effects in those patients, have a quick question for Dr Heywood. Thanks, Raj. Where is the field in the pH in terms of are we still with these ivy continuous infusion therapy that we is there something on the horizon for managing pH patients? What this sake different eso way can give Orel process the prospect cyclones or prostituted chemicals, and that helps. But the best treatment is ivy. But as you know, they need an indwelling line. And, uh, you know, they need years of therapy and the line can break. Uh, kind of they can crash. The line breaks there. There has been work on an implantable pump that goes under the skin and get and could be refilled like a chemotherapy pump, Archym or a pain pump every month or so with this medication that was gonna be released this year. But I think with a covert epidemic, it's been pushed back. But I think that will really be a boon. Toe some of these patients and make it easier to use i v Therapy for people was significantly high pressures and RV dysfunction. Thank you. Just got one other question. Do you start sgmd two inhibitors? If a patient has no diabetes? Yes. So yes, yes, yes, right. It's it's it's gonna It's really standard of care now, Andi. There'll be there'll be the guidelines. So it's It is. It is FDA approved for for DAP that the paddle flows in probably will be FDA approved for Paglia flows in next year. I suspect strongly the guidelines will come out with with recommendations next year. Strongly recommend. But the thought leaders in this area especially Dr Funeral, etcetera. You know, for him the data is clear. I think it's clear to that this is the fourth pillar. The more pillars we have to support patients unless they fall down. Okay, here are just to recap the trials that you mentioned for the inter atrial shunt. You know the preserved the F and reduce TF. So what trialing are you enrolling now? I believe you completed enrollment for one trial and you still have one trial open. Correct? Yes, that's correct. So the relieve heart failure study is still enrolling, so that's more broad. So it has, uh, inclusion criteria that incomes as any e f. So there's no e f cut off. The previous trial, which is finished, was more from preserved greater than 40%. So now, with relieve F, it is for any, uh, relief heart failures For any F low or preserved, they have had to have the hospitalization within the last year or significantly elevated anti pro BNP. And for those with reduced yet, they have to be on standard of care. As faras medicines go, Max tolerated, uh, you know, beta blockers interest O Mara, that kind of thing. So eso we are actively enrolling in that trial presently. So if you optimize, they still have heart failure. Symptoms have had a high BNP may hospital or hospital admission for heart failure. That someone you would scream Maybe. Right, Harkat, look and see if they would benefit from this trial. Enrollment? Yeah, and you know, you don't necessarily even need to do a screening. Right? Heart Cath. Really. Anybody who fits that inclusion criteria who's had a hospitalization, particularly those that have been hospitalized in the last year, you know, is Dr Heywood mentioned in his initial talk. You know, we know that those patients are at higher risk for mortality, Really, once they've had an initial hospitalization for heart failure. Eso The goal here is to look to see if we can reduce those kind of more significant outcomes the hospitalizations, the eventual need for heart failure for elder transplant on Ben in the half. Temptations. You know, it's predominantly the hearts of hospitalizations and improvement in six minute Walk a za primary endpoint there, Um, but yeah, anyone who's had a hospitalization in the last year would be a candidate. Potentially just got another question for you. Raj. What other safe and stable lab values on other markets in a patient with liver disease as a cause of Parma hypertension in order for the patient to undergo a liver transplant? So the liver markers, uh, liver markers that may suggest that the patient is safe to undergo liver transplant. Is that what you said? Yeah, very understand. So what are the safe and stable lab values and other markers in patients with liver disease as the cause of farming? Hypertension. So basically, you're trying to say the pH this patient had his liver is not cardiac related. I feel reasonably confident that you're treating the pH. You're treating the liver. You're going to transplant this patient, this patient gonna dio safe after, was the saying it's fixed for your hypertension for other reasons on. And this patient probably should not undergo a liver transplant, right? So I think what that comes down to is ensuring that it is really portal Pullman hypertension and not paying attention due to something else s O that really. You know, we work very closely with hepatology ist on that, but, um, you know any patient that comes in what we're doing an evaluation and that again is a good question. That kind of highlights how important history is. One we're doing these evaluations for Paul. My heart attention, um, in that if they've got frank cirrhosis, you know, they've had liver complications or psoriatic complications without many of the other. You know, issues that we see that can cause pulmonary potential, mixed connective tissue disease, scleroderma, those kinds of things. Um, then, you know, that's that's we feel pretty confident. The other thing is that often with these patients undergo, uh, liver pressure analysis as well so they could do sort of a paddock wedge pressure on that confirms the diagnosis of portal hypertension. So certainly if a patient has portal hypertension or even the clinical manifestations of portal hypertension and then has, uh, pulmonary hypertension. On top of that, I feel pretty confident that it's a combination of that. You know that za deliver disease that's causing that the Puerto Palmer hypertension. How did they do afterwards? Well, you know, if we get there, pressures down there, pressures have to get down. It's very similar to heart transplant in that regard that we have to get the polling pressures down under control because if they're not under control, um, then you know a new liver could fail immediately because all that pressure is going to come back and congest deliver right away. So, you know, we have to ensure that the pressures of control. And what we see is that after the liver transplant is that we can kind of pretty rapidly taper off the medicines that they're on, and then they don't really need any Pullman antihypertensive after that, just kind of nice. Got it. Take two more quick questions and then we'll jump to Dr Hayward's case. This questions for Dr Hayward. Do you maximize interest your first, and then add a sgmd two inhibitor. Try to get both patients, both agents on board in a reduced DF heart failure patient who has room with blood pressure? That's a great question. I think I'm still learning how to do that. If I think about that, if somebody has elevated blood pressures, I would probably use that to get the interest. Oh, up to the full dose as we can. We try to get up to 97 103 Often we can't get up to that dose because of blood pressure. So we get up to the blood pressure we can. So in general, I think entrust those probably the most important drugs. So I get that up first and then on. But if they're on a beta blocker, often I'm taking somebody that I've seen for a couple years. They're already on in a So I stopped the ace two days later. Start the interest. Oh, then and increase the interest over several visits once I there on a stable dose of interest. Oh, Then I would look, then I would add the SG lt two inhibitor. Now, I might change that a bit if they're quite overweight or they have diabetes and their hemoglobin, a one c is eight. I might get the hemoglobin. I might get the SGL t two inhibitor onboard sooner on then and then adjust diuretics is we need to, uh, interestingly, uh, the amount of insulin that people need once they're put on interest. Oh goes down. And the number of people that get started on insulin in the heart failure trials if they're on interest oh, is less so. Interest. Oh, seems to have some positive effects on diabetes as well. It also improves uric acid. So there's a lot of metabolic benefits that come from trust does well, thank you. Read this paper. You know, wearing interest to prevent the breakdown off endogenous insulin. So you end up having more of your native insulin and that seems to help reducing if exogenous insulin. The question I had I mean now, as far as what you mentioned, that the trialing was done with SGL T two on top off current standard medical therapy, right? Meaning beta blocker on is so it's a little bit practice child. We're trying to figure out what it's going to end up being, and so it seems that kind of practice is still some beta blocker. Some honey maximize those on Ben Sort of individualize it for patient. Who you think you know. If the heart rates that control maybe a little less beta blocker and more off SGST to one stuff, take one other question and then we'll jump to your case. Um, during cubit precautions. How best do we schedule follow up visit for ongoing management off acute on chronic heart failure? So this is a great question, A timely question, obviously. Especially, I think, the next 3 to 4 months, or until the vaccine that becomes available widely until May or June. I think what we're going to be doing, what we do, it's really triage. I mean, ideally, we'd like to see patients within a week after follow up Right now when things were quiet, we're bringing most of these patients in person and seeing them on be sort of really try to triage. If we think it's a volume related admission or that's the issue with the patient. We like to see them in person because unless they have a cardio MPs center, which is a great usually deep in this arena, because then the patient can still stay home, we can look at the p A pressures and complete the visit virtually if they don't have a cardio memes on. We're trying to get a sense of this volume. We bring that patient in in person right now. I'd say we're still about 70% of our patients we're seeing in person. I suspect that will the next 23 months is going to be like early in the pandemic, where we cut down some of the in person visit to do a little bit more virtual. Um, Andi, certainly, for the ones who have cardio members were gonna be more virtual telly medicine rather than in person. Since we can be objective on their volume status, we think the one big limitation with telemedicine visitors volume assessment in the heart failure patient. So it's striking that balance. Okay, maybe we can We have 10 minutes to a break. So I think, Dr Heywood, you could do your case. Okay. Thanks, everyone. This will be quick, I think. Yeah. So? So this is a 75 year old gentleman with ischemic cardiomyopathy F 25% narrow cure s. He was hospitalized six months ago for heart failure. For five days. We put in the cardi memes after that admission. So he was discharged on my center pro at night. 80 of Lasix from lacked own 25 carvedilol. Good. Good regimen. Granting 1.5, um 40 and terminal BNP 2000 history of diabetes for five years. Glider ride once a day. And then he comes in to see you. Uh, so when you see him, his blood pressure is 1 10/80 neck veins were up a little bit. We really focus a lot on neck veins. That's probably the best thing on the physical. Examines if their volume overloaded or not. Anything more than seven jugular venous pressure there. Fluid overloaded. Especially if they have a positive a J R. Two. I think this guy's fluid overloaded. Now I have a cardi memes and it's 24. His goal is 20 so I think he's fluid overloaded by that as well. So what would I do here? Uh, you know, should I add more diuretic? That's easy. Did almost. That's if you ever do boards ditches. Always the wrong answer. Okay, that's always the wrong answer anymore. Should I do Arnie shy? Do SGL t two inhibitor. Now he's online Sina Pro. Probably the best thing I could do for him is to get him on a nest. You will get him on the Army so would stop his listener pro at this point again for two days and then switch him over to an Arnie. So is listener Pro was stopped. We prescribed for him. So Cooper trove. I'll start in 24 26. I thought he had enough blood pressure to support the low dose. Like I said before, if I was really concerned about his blood pressure, I'd give half of this or even do just half a night to start check labs in two weeks, and then we'd probably do a phone visit after that to see what his blood pressure is to see how he's feeling. So his renal function was 17 It went up a little bit. Don't be concerned about that. That's still okay. His weights down his cardamom. 17. What should I do now? His cardi memes a little bit below goal, scratchings up slightly. So see what we did. So we actually decreased his diuretic and his neck veins were still good. His murmur went away at this point. Shoot. And this gets to the questions that we increases the Cooper Jovel certain. Should we add an SGL t two inhibitor? E. I don't think there's really a right answer here. It's dealer's choice. Um, we actually, I think, increased his sick uber trove. Al Certain it's got more energy is pressures air up at this point, he's on a pretty good dose of entr. Esto haven't added the STL. This is probably when I would add is SGL t two inhibitor. I might reduce his diuretic at this point where I might just since he has a cardio members, I probably just watch that. But so one of the issues here is it takes a number of visits to do all these things. This has not come in for a stent and go home. This is, ah, number of visits and where we are doing things on the phone, we are doing Televisa's. It's especially is Doctor, Shrivastava said. If they have a cardio, members were really happy we could do more video visits with this. So telephone visit four weeks later on the VLT two inhibitor, his his memes is down to 16. He's lost £5. Very happy blood, personal low. I probably reduce his diuretic at this point. Remember, he was on 80 a day. Now he's going to go down to 20 a day. It's funny my practice has really changed. Five years ago, I was pushing up diuretics all the time, and I still do that if need be. But also I feel now that with these new agents, if if patients are on the lower dose of diuretics, that's actually a good sign that they're better managed. So we have a lot of patients. I think Dr Mohan Intrusive would agree that we have a lot of patients now that need no diuretics whatsoever. With these newer agents So he's doing well on 20 of Lasix. We see him one month later. Is cardi memes 18. Blood pressure is that his BNP has gone from 2000 to 700. Uh, this is really a good marker at his, uh, his risk of heart failure, hospitalization or receiving mortality has gone down by about half, and a Z F now is going up. It's gone up enough that he doesn't need a CR. He doesn't need a defibrillator. So we're really benefiting him. And there's still more things to do. Go monitoring time. But probably this patient We would continue to go up on their, uh, Cooper till Val starting over time. Probably get them completely off diuretic. Um, and, you know, wait for the next new drug therapy to come along in the next five years or so for something else. But we have patients that we managed for 15 years now with heart failure, and if you keep them, you've limit. Keep them on evidence based therapy. As therapies change, patients can live very well with heart failure. As we say, we want heart failure to be their hobby, not the center of their life. So they go on and do the other things that they need to do. So I think we're gonna have a break now for half a now, er and have some, uh, exhibitors on video as well. So again, Thank you for joining us. We really appreciate in this trying time. Uh, Thio, but But patients air still sick. And not everybody has co vid and they still have heart failure. Arrhythmias, etcetera. I hope you find these tips helpful for you and managing your patients. Published February 5, 2021 Created by
