A Conversation About Heart Failure

[tks]

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Heart disease is different from heart failure. There are no medications to directly treat heart failure (though I know of some effort underway) There are multiple drugs offered along with devices etc to minimally manage heart failure.

Here is a conversation between two cardiologists about heart failure.

Milton Packer and Richard Lehman are both 66 years of age. Packer has been leading major heart failure clinical trials for decades. Lehman is a retired UK GP who writes a blog for the BMJ website. The two have agreed to answer questions and participate in a discussion about their different ideas and perspectives about heart failure.

I may post this in two parts

Source: Cardio Brief, May 2017
Link: http://www.cardiobrief.org/2017/05/...ailure-with-milton-packer-and-richard-lehman/

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Question: What do doctors get wrong about heart failure? What are the biggest and most important mistakes they make when dealing with heart failure patients? What should be the goal of treatment?


Milton Packer:


There are two types of mistakes that physicians commonly make. Interestingly, they are almost polar opposites of each other.


On the one hand, many physicians erroneously think that it is possible for patients with chronic heart failure and a reduced ejection fraction to be stable and do well. In truth, no patient with chronic heart failure is stable; they all have a progressive disease that requires aggressive treatment.

In many cases, the evidence for instability is worsening symptoms, but in many others, the disease progresses silently until the patient experiences sudden death. I have heard physicians say that they think that sudden death in a patient with heart failure is a good thing because it stops suffering or because it is a peaceful but unavoidable occurrence; they mistakenly think of it as a new arrhythmic or ischemic event. That is very unfortunate.

Most sudden deaths in patients with chronic heart failure are directly related to progression of the underlying disease, and they are largely preventable. Every death in a patient with heart failure is a regrettable occurrence, but fortunately, most deaths can be delayed for long periods of time.

At the same time and by contrast, many physicians erroneously think that heart failure is simply part of the natural way of dying. They see an elderly patient who is suffering, and they think this is an acceptable way that life can end. They think that heart failure is by its very nature an inexorable disease that is rapidly fatal, and that prolonging life means the prolongation of suffering. This is very far from the truth.

In the 21st century, patients with chronic heart failure generally show slow progression over a period of 10-15 years. Although many patients are elderly, the disease does not start late in life; it generally begins around the age of 60-65, and the treatments that we have can add many years to a patient’s lifespan. Most importantly, these are not added years of suffering. The drugs that prolong life also have significant beneficial effects on symptoms and quality of life. When we are successful (and we often are), most outpatients with heart failure are mildly symptomatic, and they can realistically look forward to many additional years of life experiences.


The key to communicating with a patient with chronic heart failure is to tell them that they have a really serious but manageable disease and that we can relieve suffering and prolong life. But you also need to tell them that treating heart failure successfully is really complicated. Most patients require at least four drugs used simultaneously and taken for very long periods of time, often in combination with devices. The conquest of heart failure is achievable, but it requires a great deal of work on the part of both the patient and the physician. Patients need to be told that they can really impact their disease, and they need to find a physician who is willing to make the commitment to do so. Too many patients are told either that they are doing well or there is nothing that can be done. Very few patients are receiving the best possible treatments that we have to provide.

Richard Lehman:


Thanks Larry for these great questions which set our conversation on a very broad path. That suits me because I have always been a complete generalist, and the heart failure patients I have seen have always been people who depended on me for all aspects of their care.


What do doctors get wrong about heart failure?

Conversation has to begin by settling the patient’s mind at rest that this horrible expression does not denote imminent death or some “failure” on their part or even their heart’s. Years ago I argued in a BMJ editorial for “impairment” rather than failure, but with little effect.

 

[tks]

Part 2

What are the biggest and most important mistakes they make when dealing with heart failure patients?


At the beginning I think a frequent mistake is information overload. Test results and therapeutic possibilities can be set out at length to the exclusion of eliciting the patient’s level of understanding and their own goals for treatment. Another mistake may be to focus on their heart failure without consideration of their other health problems.

Subsequently it may consist of ignoring mundane but vital aspects of their lives while pursuing biochemical values, “objective” measures of function, and particular target drug levels. In the end stage, it may consist of piling on medication and inserting devices rather than having difficult conversations about the aims of care and the limitations of what is available.


What should be the goal of treatment?


I think it should be the sharing of a difficult journey in the kindest and most effective way possible, constantly informed both by the evidence and by the wishes of each individual.

 

[GANESH65]

Good informative posts TKS ji thanks for sharing

 

[tks]

Good informative posts TKS ji thanks for sharing

Thank you Sri Ganesh.

1 in 9 deaths in USA is attributed to heart failure. There is really no drugs in the market to treat the condition but drugs only exist to manage the situation (which is what the conversation posted above highlighted)

Current Cardiovascular drugs address heart diseases (not those attributed to heart failure) in the following manner.

1. Lowering blood pressure
2. Reducing Glucotoxicity (e.g., Metformin etc)
3. Reducing Cholestrol (e.g., statins)

None of the above address heart failure issues. If the problem is correctly diagnosed the progression of the problem can be managed well.

I did not know for a long time that heart failure (which is very prevalent) is different from other heart diseases .

Those that end up getting chemo therapy (which is really several poisons put together) may develop symptoms of heart failure (I think one medicine/poison had that effect depending on the quantity level administered)

Anyway that is just my layman's understanding of the issue..

 

[tks]

Conversation continues in this next edition ...

Should Everyone With Heart Failure Get Aggressive Treatment?

–A Conversation About Heart Failure With Milton Packer And Richard Lehman (Part 2) - Date May 23, 2017


This is the second installment of an ongoing discussion about heart failure between Milton Packer, who has been leading major heart failure clinical trials for decades, and Richard Lehman, a retired UK GP who writes a blog for the BMJ website. (Click here to read the first installment of this series.)


In this episode I asked Richard Lehman to respond more fully to this statement made by Packer:


“In truth, no patient with chronic heart failure is stable; they all have a progressive disease that requires aggressive treatment.”

Richard Lehman:


As with most of what Milton has said so far, I am in broad agreement, and greatly value his positive approach. The potential for instability is always there in chronic heart failure, and clinicians should always be on the lookout for treatable causes, since every episode of decompensation has a reason. Unfortunately, attempts to predict these episodes have been largely unsuccessful– telemonitoring, daily weighing, measuring B-type natriuretic peptide and so on. I hope Milton agrees that we should not make the lives of patients more burdensome by intensive monitoring unless we have good evidence that it helps towards some goal – e.g. prolongation of life, avoidance of hospital admission – which we know truly matters to them.

Working in British primary care for over 35 years, I am seeing heart failure from a perspective that differs in three ways from Milton’s. First of all there are the cultural differences between US and UK medicine, including the way we use words. “Aggressive” always carries a bad meaning for British patients. “Intensive” or “thorough” would work better over here. But that’s a minor point. Secondly, our patients in general practice rarely move doctors, so we see them right through their lives, look after all their conditions, coordinate their care, and explain the process as we go along. So in many cases the management of their heart failure may not be the only factor in their medical management, and there may also be non-medical factors which influence our management. Thirdly, the epidemiology of heart failure in UK primary care suggests a different pattern from the one Milton describes. The latest paper came last month from some Oxford colleagues.


This study does not determine the mean age at diagnosis for heart failure in the UK, but the investigators confirm that it remains at 76. And the analysis does not distinguish between HF with or without reduced ejection fraction, though the latter diagnosis is only grudgingly accepted by most UK physicians, and the THIN database used here would heavily favour an echocardiographic diagnosis of HF with reduced systolic ejection fraction. Of note is that the prognosis of HF in the UK has not improved over the 15 years studied, despite the widespread introduction of HF prescribing incentive schemes, heart failure clinics and community services.


I will stop at this point. I would be very interested to hear how Milton views this: whether the US situation is different, and in what ways we might look to make services more effective.


Milton Packer:


It is amazing how much Richard and I agree. Let me count the ways!


I absolutely agree that we should not make the lives of patients more burdensome by intensive monitoring. I do not believe in telemonitoring or repeated measurement of B-type natriuretic peptide; they are not useful.


I also agree that every episode of decompensation has a reason, but the reason is not generally the occurrence of a new event; it is simply progression of the underlying disease. Consider the analogy between heavy snow accumulating on a mountain-side and the progression of left ventricular dysfunction. Eventually, there is sufficient stress that there is an avalanche. To an outside observer, both appear to be acute events, but in both cases, there is typically no new precipitating cause (other than one additional snowflake or myocyte!). If we are going to prevent events that matter to patients (death and hospitalization), we need to focus on slowing the progression of the underlying illness. There is no other rational approach.

I also agree that Richard’s experience is totally different than mine. He kindly postulates that there may be cultural reasons, based perhaps on geography or perhaps on the differences between primary and tertiary care. I do not think so. I also do not believe that age is an explanatory factor. Is there an identifiable age at which time I would not care about living and living comfortably? I hope not. Yet, there is a critical difference between the patients who seek help from Richard and those who seek help from me. Richard’s patients have looked to him for help all of their lives, and he provides critical levels of comfort on multiple different levels. The patients who seek my help are not primarily seeking that kind of support (not that I fail to provide it!). Instead, they come to me (after having seen many other physicians before me) because they are desperately tired of suffering and extremely afraid of dying. They ask me: what is the best that medicine can offer? I tell them there is a good path forward, but it is complicated and difficult; yet, if both the patient and the physician are committed, there is so much we can do.


So I think that there is a simple explanation for why my experiences and Richard’s are so different. We both give our patients what they are seeking and value. It is just that the patients he sees and the patients I see have markedly different expectations. That is perfectly OK. That is why both Richard and I exist; we both provide hope, comfort and a path forward. Neither of us is in a position to tell patients what they should value; but we do need to respond very positively to why patients have come to see us.

 

[tks]

Conversation Continues - Part 3

–Milton Packer and Richard Lehman compare perspectives, Part 3


This is the third installment of an ongoing discussion about heart failure (HF) between Milton Packer MD, who has been leading major heart failure clinical trials for decades, and Richard Lehman, MA, BM, BCh, MRCGP, a retired U.K. GP who writes a blog for the BMJ website.

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In response to this series one reader on Twitter, a caretaker for an aging father, raised a difficult issue: “Biggest question is how/when end stage determined & care shifts: cruel or kind?” What are your thoughts about this?


Milton Packer:


“I think of myself first as a human being, second as a philosopher amazed and entertained by the universe, third as a physician, and last as a clinical trialist. So from my perspective, the point raised in this tweet (so eloquently articulated) confuses me. Do we actually live in a binary world where we suddenly make a decision to move from intensive care to supportive care? What can we possibly mean when we use the term “end-stage”? Does comprehensive and compassionate care ever really shift at a specific point in time? Let me provide two real examples from my own experience.


A 63-year-old man is brought to me by his family. He smoked cigarettes and abused alcohol all of this life and avoided seeking medical care for his hypertension. He suffered a disabling stroke a few years before, has substantial impairment of kidney function, is not ambulatory and is horrified by his life. Most of the time, he refuses to take the medicines that are prescribed for him. His family has just been told that he has heart failure with a reduced ejection fraction, and wants me to make him better. I tell them that his heart failure is the least of his difficulties, and that whatever I do, I will not make a real difference, and I could make things worse. They leave disappointed because they were told (before their visit) that I could work miracles.


A 79-year-old woman comes to see me and is accompanied by her daughter. She has suffered several heart attacks in the past few years, and now, cannot function because she has disabling shortness of breath that overwhelms her after a few steps. She has seen many physicians before me who have told her that her heart is on its last legs. Yet, upon reviewing her medications, it is clear that she has been receiving terribly suboptimal care. For some reason, she takes only one of the many medications she needs, but at the wrong dose, and many critical elements of treatment are missing. She has been told by her physicians that nothing else can be done. She tells me that she really wants to get better; she wants to see her grandchildren grow up and she loves the outdoors. I tell her that there is much that we can do, but it will take time and we need her commitment. Nine months later, after implementing many changes in her medical regimen, she has returned to living her normal life and is delighted to go on long walks in a beautiful (but somewhat hilly) region near her home. She asks me how long this improvement can continue. I tell her I want to be invited to her 90th birthday party.


Which of these patients should be given the label of “end-stage disease”? Given these examples, is this still a question that needs to be answered? My response is a simple one: if I can make a meaningful difference in a person’s quality or quantity of life, I will not hesitate to do it. It is not more complicated than that.”


Richard Lehman:


This question is raised by the carer of a father with longstanding heart failure, and I’m going to address it as someone who has been through the same thing with his own father, albeit 25 years ago. I do think that the “care shift” problem is still a deep issue for many who want to see their loved ones get the best treatment but who are often faced with the increasing nearness of death. Treatments that previously helped no longer do so. In fact the burden of treatment can be additional to the burden of symptoms, as each day brings added premonitions of death, with no certainty about when or how it might happen.


Since my father’s time, thanks to the immense work of Milton and other leading trialists, we have many more options to prolong life in patients with systolic heart failure. In the first part of our conversation, Milton said that “The key to communicating with a patient with chronic heart failure is to tell them that they have a really serious but manageable disease and that we can relieve suffering and prolong life. But you also need to tell them that treating heart failure successfully is really complicated.” I agree. In fact given the complexity involved, I believe that if we can crack the art of sharing decisions in heart failure, we can do it for just about anything.


But for now I’ll return to the case of the carer’s father who has advanced HF and has been on treatment for years. Twelve years ago I helped to collect a database of video narratives which included such people and those looking after them at home. Social isolation, depression, inability to do anything enjoyable, constant weakness, uncertainty are just some of the themes. A kind and knowledgeable cardiologist is a wonderful asset to such patients but as they get closer to death, they need more help than any individual can provide alone.


For a long time I bought into the “hand over” model of thinking and thought of mechanistic ways – for example measuring BNP – to persuade cardiologists that the time had come to hand over to palliative care. I don’t think that way any more. Although in the past I’ve been a carer for my father, a GP and an out-of-hours palliative care doctor in my career, I think I need to get humble and find out more about the real needs of patients with longstanding heart failure and the carers and relatives who have shared their lives (day and night) for years. Fortunately a group of us (the rest much younger than me) have just got funding to determine research priorities for advanced heart failure directly by bringing together patients, carers and front-line clinicians. There is a terrific UK organization which was set up to do this across any and all medical conditions, called the James Lind Alliance.


I see the eventual solution here in a radically better system of training in communication and collaboration for all health professionals, and the development of systems of integrated care which are truly patient-centered. I would like to see a blurring of boundaries between specialist and end-of-life care. This may sound vague and aspirational but I make no apologies for that. To me this sharing of knowledge, skills and values is the only way in which the great store of evidence, which Milton and others have worked their lives to accumulate, can most humanely and effectively be applied to the care of individuals reaching the end of their journey.