Never take it easy

It is estimated that we have a minimum of 14 lakh patients with heart failure (HF) in Jammu and Kashmir as per the population-based statistics. A large number of them have HF with weak hearts where the pumping function is poor because of low left ventricular ejection fraction (LVEF).

These patients need evidence based medical treatment which improves their symptoms and to some extent their longevity. However, in spite of continuing the treatment a number of them worsen and need intensification of treatment and eventual hospitalization.

Case Study

Mr M S B a 59-year-old diabetic suffered a heart attack labelled as anterior wall MI in March 2020. He presented to the hospital next day (after 10 hours) and was given prompt attention given appropriate medications and taken for angiography and a drug eluting coronary stent was put across a blocked major artery (Left anterior descending, LAD). After 3 days he was sent home. His heart functioning was weakened, left ventricular Ejection Fraction (LVEF) of 35% (Normal LVEF is more than 50 to 55%). He was put on standard treatment for HF with low LVEF.

This treatment consisted of Sacubitril valsartan combination (ARNI), metoprolol, dapagliflozin and spironolactone (four pillars of HF treatment) in appropriate doses.

He was examined and evaluated by a few more cardiologists also. All agreed with this treatment. He continued his work of a business executive comfortably for a few years when he started noticing shortness of breath and mild cough.

He took antibiotics and cough syrup for a week but without much relief. A few days later he got up past midnight severely breathless and woke up his wife and went to hospital emergency, where a diagnosis of acute decompensated heart failure was made.

He was admitted and given intravenous furosemide and shifted to ICU. After stabilization an angiogram was done which showed patent stent and no additional blocks in the arteries were found. He stabilized after adding diuretics and was discharged. His ECG and echocardiographic findings were unchanged.

After discharge he however started getting fatigued and never felt the same as he used to be before getting the recent sickness. He modified his scheduled, avoided walking long distances and preferred to take a vehicle to go to market and became very concerned about his health. However, despite leading a restricted life style he again had increasing shortness of breath and required another hospitalization after 3 months with decompensation.

Worsening Heart Failure:

This phenomenon of worsening in symptoms leading to hospitalization is called worsening heart failure (WHF). Total mortality and non-elective rehospitalizations rates of this entity were 7% and 24% at 30 days respectively and 18% and 46% respectively at one year according to a large European registry.

This phenomenon actually is a progression of underlying disease which is a weak heart muscle and needs intensification of treatment most often with a diuretic. Once it reaches this state the mortality is high.

A lot of research and clinical trials have been going on this direction and a drug which is an oral soluble guanylate cyclase stimulator named Verciguat, available as Verquvo has been shown to be effective in patients with the clinical picture presented above.

This drug actually stimulates the cyclic guanosine cyclase (s GC) which results in relaxation of smooth muscle cells, reduction in hypertrophy, inflammation and fibrosis.

Once acute HF develops the mortality and recurrences are high. The answer therefore is an early detection during the outpatients’ visits and preventing the episodes needing acute intensification of treatment. The focus should be on how to do it. Here are some of the tips for the general information for such patients and their family members.

1 High Index of Suspicion: Patients with chronic HF should be careful about weight gain, cough, increasing shortness of breath, new onset easy fatiguability, chest discomfort on exertion, and an   increase in pulse rate.

Clinical examination is useful but the signs like fluid accumulation manifesting as increase neck venous pressure and basal lung crepitations on chest auscultation are late signs when the patient is very close to frank heart failure needing emergency department visit or intravenous drugs. A number of heart failure scores have been made but the utility is limited. Early detection of symptoms is important but are highly subjective. Test like 6 Minutes’ walk test which are recommended but are seldom practiced by our health care workers. The aim of early detection is to prevent a potential hospitalization with its associated high mortality, cost and demoralization of the patient and the family.

2. Biomarkers: Detection of high levels of biomarkers in the blood may help early detection of HF in a person before frank picture emerges. A number of them have been studied; -CHF carbohydrate antigen 125 (CA-125), Biologically active adrenomedullin (bio-ADM), NT pro BNP, Troponin, soluble suppression of tumorigenicity 2 (sST2) being the most often mentioned.

Elevated NT-pro BNP and troponin have however been identified as the most widely used to screen such patients for early identification of WHF supplementing the clinical suspicion. In patients with serially high levels a response to therapy by getting lowered biomarkers indicates a favourable response to addition of drugs like Verciguat ,  in patients already on the other drugs.

3. Imaging: Echocardiography is an important tool for assessing signs of congestion in these patients. These are inferior vena cava diameter, pulmonary artery pressure, estimation of left ventricular filling pressures and diastolic dysfunction such as E/e’ ratio.

Ultrasound is also useful to measure lung B lines, jugular vein diameter and intra-renal venous flow. These all are useful in detecting early congestion before a florid picture emerges.

4. Devices: Implantable monitoring systems help in getting a summary of the recordings of hemodynamic parameters to the treating team. It facilitates home monitoring and can detect worsening heart failure when it is still sub-clinical. These thus can allow prompt adjustment of the therapies. These devices however are not used much in our population with HF, because of the cost and the ultimate benefit still not being clear.

TREATMENT: Once the patient has full blown HF treatment is hospitalization and intensification of the treatment especially with diuretics and sometimes inotropes if arterial pressures are low.

The key is to catch these patients early during outpatient visits at the stage when adding diuretic or escalating its dose or changing the drug begins. This is the stage when adding the fifth drug Verciguat should start. Meanwhile optimization of the dose of other drugs should also be done simultaneously. Verciguat has the advantage that it can be given even in patients with chronic kidney disease and relatively low arterial pressures of up to 95 to 100 mms Hg. Chronic kidney disease is often an accompaniment of WHF and some of the drugs like ARNI and spironolactone cannot be given in these sick patients.

Need of the day is to be aggressive in the management of heart failure especially in those presenting as WHF. Heart failure mortality is high like many cancers and treatment therefore has to be multi-pronged and started early. The four pillars of heart failure treatment need to be upgraded to quintuplet therapy once earliest signs of WHF have been detected.

Prof Upendra Kaul is a renowned cardiologist, and Founder Director Gauri Kaul Foundation