Regional Cardiology Congress : Current Updates on Heart Failure

Opening: Current Updates on Heart Failure Guidelines 2021

Host  00:11 Hello, good evening to all Docquity users across Southeast Asia and Taiwan. My name is Patrick, represent Docquity Global. I welcome you all to the first Regional Cardiology Series. Today we will focus on talking about heart failure. With us now, we have very distinguished, very honored to welcome distinguished speakers and moderators that come from different countries and join us virtually. Without further ado, let me introduce our moderator.

Host  00:50 Our moderator is Dr. Indah Sukmawati, MD, FIHA. She's a Staff Lecturer at the Cardiovascular Department, Medical Faculty of Universitas Pelita Harapan. She's also a Cardiologist at Siloam Hospitals Lippo Village, Tangerang, Indonesia. Right now, she is a Secretary of the Women Cardiology Working Group of the Indonesian Heart Association, Head Coordinator of Indonesian Heart Association, Banten Chapter Book Publishing, and also a Social Media Consultant at Journal of American College of Cardiology Case Reports. She's finishing Observership in Interventional Cardiology Program at Cleveland Clinic, Ohio, and Observership in Heart Failure Program at National Heart Center, Singapore. So, Dr. Indah, the time is yours.

Introduction

Dr. Indah Sukmawati  01:44 Thank you, Patrick, and the whole Docquity team for organizing this as part of the Regional Cardiology Series. And without further ado, I want to introduce our first speaker for tonight. Dr. Ong Hean Yee. Can you please pull up his CV? Thank you. Dr. Ong Hean Yee: he's the immediate past president of the Singapore Cardiac Society, and he is currently a Senior Consultant for the Cardiac Solutions Medical Center and Mount Elizabeth Novena Medical Center Singapore. Dr. Ong Hean Yee has more than 25 years of clinical experience, including seven years in the National Health Service in the United Kingdom and 15 years in public hospitals in Singapore. He completed his Advanced Imaging Fellowship in Echocardiography and Cardiac CT at the Cleveland Clinic, Ohio, USA. He has special clinical and research interests in various areas of Advanced Cardiac Imaging, Cardiac Screening, Complex Heart Valve Disease, Hyperlipidemia, Exercise Testing, and Heart Failure.

Dr. Indah Sukmawati  02:43 Tonight, we are going to learn from him about "Desperately Seeking Heart Failure: The Objective Diagnostic Methods for Heart Failure." Without further ado, Dr. Ong, you can proceed with your presentation.

The Objective Diagnostic Methods for Heart Failure Based on Heart Failure Guidelines 2021

Dr. Ong Hean Yee  02:57 Thank you, just share my screen first. Thanks, Docquity team and Dr. Indah, for the kind introduction. I miss meeting up with you guys, and I miss meeting up with Gilbert, the next speaker as well. Today, we're going to talk about "Desperately Seeking Heart Failure: The Objective Diagnostic Methods for Heart Failure." These are my disclosures.

Case 1: 47-year-old Chinese male with obvious symptoms from HFrEF

Dr. Ong Hean Yee  03:26 Maybe I started with two cases. The first case is a 47-year-old Chinese male who presented with two weeks of breathlessness and, in particular paroxysmal nocturnal dyspnea, especially at night. And he had two days of leg edema, which triggered the current remission.

Dr. Ong Hean Yee  03:42 This is his ECG showing Goldberger's triad per hour with progression. Deep S and tall R, and poor voltages. His x-ray shows cardiomegaly but no pulmonary edema. His echocardiogram was clear cut and showed a very poor ejection fraction with a bit of functional MR (Mitral regurgitation) as well. His BNP markedly elevated 4454 with a raised Troponin T, in the raised Troponin T. We did the coronary angiogram, which was completely normal.

Dr. Ong Hean Yee  04:18 So this patient has heart failure reduced ejection fraction (HFrEF), clear cut symptoms/signs of leg edema with paroxysmal nocturnal dyspnea, poor ejection fraction, and raised NT-proBNP. It is quite obvious.

Case 2: 45-year-old European female with primary COVID-19 vaccine completion and no obvious HF symptoms

Dr. Ong Hean Yee  04:34 My second patient is a 45-year-old European female. She completed her primary COVID-19 vaccine with mRNA vaccine in October 2021, referred by a gastroenterologist. In November 2021, about a month, she complained about an increased weight gain, reduced exercise tolerance, and a vague description of fullness in the head, neck, and abdomen. Her abdominal symptom was the one that triggered the visit to a gastroenterologist. My friend, who was a clinician, asked her to see me instead.

Dr. Ong Hean Yee  05:11 On the examination, she is very healthy. She looked very healthy and physically active lady. She appeared to have distended neck veins and turned out to be raised JVP. No edema at all in the peripheries and no pulmonary edema on examination, blood pressure and heart rate were all normal. The echocardiogram shows quite normal systolic function. However, her septal E/e' was slightly elevated at 13.4. I sent off some blood work, and the NT-proBNP was actually elevated at 356 pg/mL. This is quite unusual in a young, healthy adult with normal renal function.

Dr. Ong Hean Yee  05:53 Based on that, we started on RAS (renin-angiotensin) blockade, she could only tolerate spironolactone, and her BNP went down to about 184 on treatment. After that, she went back to Europe for a holiday to visit her family, and she came off treatment on her own. Upon return to Singapore, we tested her BNP again. It had gone back to 247. So she clearly has heart failure.

Dr. Ong Hean Yee  06:19 Preserved EF, her symptoms/signs are not very obvious. She has raised JVP, but that's about it and reduced exercise tolerance. Echocardiographic features were subtle, with only normal EF and a raised septal E/e' ratio. Biochemistry was the one that gave it away, with a raised NT-proBNP.

Looking for Heart Failure

Dr. Ong Hean Yee  06:39 So we are talking about looking for heart failure. On the one hand, we have case one, with a very clear-cut presentation with clear-cut imaging features. On the other hand, we have case two, with very equivocal symptoms, very equivocal signs, and very minimal features seen on the echocardiogram.

Dr. Ong Hean Yee  06:59 So what is the sine qua non of heart failure, and what is the defining feature of heart failure? Ejection fraction is not heart failure.

Dr. Ong Hean Yee  07:06 And we must go back in time. In the 1980s, you look back at all the heart failure papers before 1980, and no one ever mentions ejection fraction. The diagnosis for the first captopril heart failure study was based on the low cardiac index, high wedge pressure, and high systemic vascular resistance. It's only in the 1980s, the mid-1980s, that we start seeing ejection fraction being used in clinical trials for heart failure.

Dr. Ong Hean Yee  07:34 And the reason is this. By the 1970s, we knew that patients with low ejection fraction were more likely to raise LVEDP compared to patients with so-called preserved ejection fraction and heart failure. The ejection fraction is very hard to measure. We either had to do an invasive coronary angiogram with LV gram, or we needed to send a patient for a gamma camera using radioactive isotopes. This was expensive, radioactive, and not convenient to be performed routinely. And this was because, in the 70s and 80s, computer technology was very poor, and the best echocardiographic machines could only give you grainy images, which were not ideal for measuring EF at all. But with the advance of the Motorola 6800, microchips, machines such as the Apple Mac, and echocardiography graphic machines, such as HP Sonos in the 1980s, became more widely available, and most hospitals could afford to have the echocardiographic machines by the mid or late 1980s.

Dr. Ong Hean Yee  08:45 Heart failure was never defined by EF. Raised LVEDP was strongly associated with heart failure. The echocardiographic machine became cheap, and it became easy to access EF, enhancing most clinical trials from the 1980s that used EF as inclusion criteria. Therefore we have associated it heavily with EF ever since the 1980s.

Dr. Ong Hean Yee  09:10 How do we get heart failure when there's a preserved EF? We must remember that preserved EF is not benign. Heart failure preserved EF is not a benign disease. This is our local Singapore registry data. The poor prognosis for heart failure with reduced EF is quite bad at 20%, and although the prognosis of heart failure with preserved EF is slightly better at 10%, it is still quite a bad number.

Heart Failure Preserved EF

Dr. Ong Hean Yee  09:38 This Michael R. Zile paper in 2004 discussed heart failure preserved EF very beautifully. It shows that patients with heart failure preserved EF had a much higher, much deeper volume pressure curve. And what does this mean? Your pressure-volume loop defines that your LVEDP in heart failure preserved EF is much higher than the LVEDP of someone with a normal EF.

Dr. Ong Hean Yee  10:12 For patients with reduced EF, again, your pressure-volume curve goes up as your LV volume goes up. And therefore, patients with reduced EF and dilated hearts have a higher LVEDP because their heart is bigger.

What is Heart Failure?

Dr. Ong Hean Yee  10:29 So, heart failure is actually raised filling pressure and the inability to amend output without increasing filling pressure. And that's precisely the reason why LV end-diastolic pressure is very, very important in heart failure. So, the heart is actually a high-pressure and low-pressure system. The high pressure is in the LV, and the low pressure is in the RV, including the left atrium. During systole, the heart will generate high pressures to push the blood out of the rest of the body.

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