Hello. My name is Dr Payal Kohli. I am a noninvasive and preventive cardiologist, founder and medical director of Cherry Creek Heart, and assistant clinical professor of medicine at University of Colorado, Anschutz. Today we're discussing heart failure prevention strategies: what you can do and how you can educate your patients.
I want to talk about prevention in a way that we don't normally think about. We are so good at thinking about atherosclerotic cardiovascular disease prevention, but heart failure prevention has become a new focus scientifically. As a preventive cardiologist, I'm thrilled to see this change because many of the principles of atherosclerotic cardiovascular disease prevention could be very easily applied to heart failure prevention.
If you think about what has happened in medicine over the past several decades, there's really been a shift in our philosophy to start to identify patients earlier and earlier in their disease process, before they manifest symptomatically, so that we can change the trajectory of their disease. This is one of the most powerful things that we do as clinicians. I like to call this proactive medicine rather than reactive medicine.
Obstructing the Disease Course
Let's talk a little bit today about stages A and B of heart failure and how we can prevent them from progressing. Stage A is basically when a person is at high risk for heart failure but has not yet developed symptoms and has not yet developed any structural abnormalities. This is someone warning you that they're headed toward that heart failure "destination." It's time for you to help them wake up and clean up their act.
As a preventive cardiologist, this is a place where I really love to see my patients at because I feel like I can start to make an impact, educate them about their disease process, and really help them to change that.
Let's talk about, for example, a patient who has hypertension. We know that hypertensive heart disease, where the heart muscle burns out after a while, is a big cause of structural abnormalities, including left ventricular hypertrophy, atrial dilation, as well as reduction in ejection fraction. Aggressive management of hypertension, both with diet and lifestyle as well as with medications, is really important.
There are other things to consider, of course, like smoking. The mnemonic I like to use that often sticks with my patients is the ABCDs of heart failure prevention. "A" stands for activity. We want to encourage our patients to get at least 30 minutes of moderate-intensity exercise every day, at least five times a week. We know that exercise releases chemicals called endorphins, helps with endothelial function, and it really does help improve heart and vascular health to the point where it can really have a dramatic benefit on incident heart failure.
"B" stands for blood pressure. You really want to target any potential issues early and aggressively, screen patients for hypertension, of course, and if they develop it, make sure that they are maintaining that optimal goal, which for most of our patients is going to be less than 130/80 mm Hg.
"C" stands for cholesterol. If somebody has high low-density lipoprotein (LDL), you know that the natural history of that disease is going to be deposition of that LDL in the endothelium and subsequent inflammation. You want to try to target that early to reduce their lifetime risk. I have patients, for example, who are in their 30s and 40s who I am placing on LDL-lowering therapy because I don't want them, in their 50s and 60s, to start to have coronary events or start to have coronary artery disease. "C" also stands for cigarettes. If somebody smokes, you've got to get them off of those cigarettes.
"D," I like to say, stands for type 2 diabetes. If somebody has type 2 diabetes, they're at very high risk of developing structural heart abnormalities, developing vascular disease. These are patients who you want to manage aggressively. In the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, it's recommended that patients with type 2 diabetes who are at stage A and don't yet have disease or symptoms should be treated with sodium-glucose cotransporter 2 (SGLT2) inhibitors. That "signal" for using this agent as a preventive has emerged with this class of medications, which actually reduces risk for incident heart failure in our diabetic patients. We're starting to learn about catching the disease early with the ABCDs of prevention.
We also have risk estimators, just like with coronary artery disease. When you're trying to assess somebody's risk of developing blockages, you can put all their numbers into something called a pooled cohort risk estimator. With heart failure, you have a tool called the Pooled Cohort Equations to Prevent Heart Failure, which is something you could potentially use with certain individuals to try to estimate their lifetime risk.
Of course, don't forget to ask patients about family history because we know that some percentage of cardiomyopathies are inherited. I like to call these the ABCDs of cardiovascular prevention for stage A.
Preempting Stage B HF From Progressing
Let's talk about stage B; that's when that warning that the disease is giving you just got a little bit louder because it's almost ready to progress to stage C. The difference between stage A and stage B is that the patients have structural abnormalities in stage B.
Structural abnormalities can look like left ventricular hypertrophy, atrial dilation, left ventricle dilation, or valvular heart disease. This is basically when the heart has started to feel the effects of the disease progression, whether it's a result of patients' risk factors or valvular heart disease or whatever their risks are for incident heart failure. The heart has started to manifest those changes structurally.
Now, patients don't yet have symptoms in stage B, and that's the distinction between stage B and stage C, where they end up having symptoms. Our goal as clinicians is to prevent them from ever progressing to stage C.
The nice thing about heart failure is that it follows a reliable trajectory. We know that those progressions are going to occur from stages A to B to C to D, and we really want to try to catch them as early as possible and modify risk as much as possible.
When it comes to managing our patients with stage B heart failure, most of the precautions I talked about in stage A also apply to stage B. On top of that, I would suggest additional precautions. You want to make sure that these patients are vaccinated. Keeping their vaccinations up-to-date can reduce their risk for incident heart disease. If they have a reduction in their ejection fraction, there are a few medications that you should be prescribing. These are, particularly, medications that are going to change or inhibit adverse ventricular remodeling.
If a patient's heart pump is already looking like it's gotten weak, whether that's because of a heart attack, high blood pressure, or valvular heart disease, as the case may be, you want to rest that heart muscle as much as possible. You want to interrupt those neurohormonal signals.
How do you rest a muscle that's beating all the time? Well, you prescribe medications like beta-blockers, which reduce the neurohormonal activation. They reduce our sympathetic nervous system so the heart is not working harder and faster. You prescribe medications like angiotensin-converting enzyme (ACE) inhibitors, which inhibit the renin-angiotensin-aldosterone system (RAAS). They reduce adverse remodeling and fibrosis, and they can help with inflammation as well.
You want to continue to treat whatever underlying conditions patients may have, whether it's coronary disease, valvular heart disease, or hypertension. Treat those conditions aggressively with medications like statins, antihypertensives, and other lipid-lowering therapies because at this point, again, the heart has already started to feel the effects of whatever that insult is to the heart muscle.
For patients who are in stage B, that's when I start to think about biomarkers. Sometimes I do think about biomarkers for those who are in stage A as well, especially if they're particularly high risk. I might get a screening of NT-proBNP or BNP levels, which are the brain natriuretic peptides. Once patients have started dilating their atria or ventricle or started to have left ventricular hypertrophy, you know that the cardiac pressures are affected.
Therefore, those markers of stretch, like the BNPs, can start to increase. That can be another way in which the disease warns us as to what's about to happen, because those markers go up and we know that occurs before the clinical event happens, before the patient gets edema, and before they start experiencing shortness of breath. That's something you want to think about checking, because if those markers are elevated in stage B patients, then you want to be even more aggressive about starting them on some of the additional heart failure medications.
We know that in stage C, there are four pillars of management: beta-blockers for sympathetic nervous system blockade; ACE inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors for RAAS blockade; mineralocorticoid receptor antagonists for blocking the RAAS as well; and then the newest agent is the SGLT2 inhibitor. If your patient is at advanced stage B, you may want to start to think about prescribing some of these interventions as well.
Heart failure is one of my favorite diseases to treat because it's reliable and it responds very well to therapy. I know that if I am doing the right things by my patients, such as introducing them to all these medications, educating them about the importance of compliance, about risk factor management, and about prevention, I can make a tremendous impact on their morbidity, their mortality, and their prognosis.
Sometimes we even see reverse left ventricular remodeling in some patients. You can see stage B actually go back to stage A, which means that their ejection fraction has recovered and the heart is structurally normal. That is one of the most rewarding things I will see in clinical practice.
I'm thrilled that, as preventive cardiologists in 2023, we are at the stage where we have so many tools in our toolbox, and not only for coronary artery disease. Now we can start to think about other conditions, like congestive heart failure. We can think about its pathophysiology and try to interrupt that process early and aggressively through education, interventions, and risk prediction.
Certainly, the AHA/ACC/HFSA guidelines have put their nickel down on the importance of thinking about stages A and B heart failure and not only waiting for stage C — of thinking about some of these guideline-directed medical therapies and some of these interventions as preventive strategies.
https://www.medscape.com/viewarticle/989001
