Congestive Heart Failure: Community Impact and New Treatment Paradigms

This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Hello and welcome to the show. You're listening to Weekly Dose of Wellness, brought to you by MemorialCare Health System, I am Deborah Howell, and today's guest is Dr. Ryland Melford III. Dr. Melford is currently with the South Orange County Cardiology Group. His special clinical interest is in heart failure management and cardiac imaging modalities. Dr. Melford practices at Saddleback Memorial Medical Center and is very passionate about his topic today. Welcome, Dr. Melford.

Ryland Melford III, MD: Well, thank you. Thank you. I'm happy to be here this morning.

Deborah Howell (Host): Today, let's talk about congestive heart failure and some of the new treatments for this condition. As always, we like to start with a definition of what we're talking about. So if you could, please tell us in layman's terms just what congestive heart failure involves.

Ryland Melford III, MD: Right. So congestive heart failure, it's a bit of a misnomer to some degree. You know, when we use the word failure, it's actually not my favorite word to describe the syndrome. But really what we're talking about is an inability of the heart to pump sufficient blood to meet the body's needs. Okay. So a reduction in what we call cardiac output. And what goes along with that syndrome typically are congestive symptoms, which is where the congestive term comes into play. And that is the process that is associated with increased or excess volume or extra fluid, if you will, that can accumulate in the lungs. or in the extremities and cause swelling. So that's the general definition. It comprises those two elements, a reduction in pump function or inadequate blood supply to the body or congestive symptoms.

Deborah Howell (Host): What would cause the pump to not perform optimally?

Ryland Melford III, MD: Right, that's an excellent question. 60 to 75% of cases, Deborah, are associated with ischemic heart disease. As you know, coronary artery disease is very common in our population. So when a person suffers a heart attack, the consequences of that are often some degree of pump failure. Some of the heart muscle dies. That would be the most common cause. Other causes that are relatively prevalent, especially in the United States and in developed countries, are hypertension, or valvular heart disease, such as mitral regurgitation or aortic stenosis. There are rare phenomena as well that can cause the diagnosis, but those are the primary elements that we see in this country.

Deborah Howell (Host): In 30 seconds, you just clarified for me, both my mother and my sister were affected by this, and I never understood it. But thank you so much because now I see the muscles weakening in the heart, and I can understand why, and I can understand why that would affect the pumping. So thank you very much for your clear assessment of that. So what are the current treatment strategies available to patients with CHF today at Saddleback Memorial?

Ryland Melford III, MD: Right. So, you know, at Saddleback Memorial, we exist in a unique circumstance. You know, we are, as you know, we're physically adjacent to Laguna Woods Village, which is, you know, a very large, greater than 25,000 person elderly community. And it's important to remember that this is a disease of the elderly. 10% of those over the age of 65 have heart failure. So we have worked very hard for several years to develop an optimal strategy to take care of these patients. And that begins, and I think this can't be stressed enough, that begins with medication. Beginning in the 90s, there were several clinical trials that demonstrated that medications like ACE inhibitors, beta blockers, angiotensin receptor blockers, aldosterone antagonist, so specific classes of medication - could not only improve symptoms in patients with heart failure, but also reduce mortality and make them live longer and this this was unique. So we certainly focus first on medications and we've been recognized by the American Heart Association with their gold classification, forget with the guidelines, which is basically identifies us as an institution that is adherent with the National Guidelines for Medication Utilization. We've had that certification since 2006. I would say though that more recently there's been a transition in the paradigm of focus for heart failure management towards more device-based therapy. And we've implemented those therapies at Saddleback as well. For instance, we have the capacity to implant cardioverter defibrillators, which are devices that can pace or shock the heart if a patient develops a life-threatening rhythm disorder and can reduce the likelihood of death by up to 25% in the clinical trials. We have the capacity to place special pacemakers that more recently have been shown to improve symptoms in mortality, and we call those biventricular pacemakers or biventricular defibrillators. So this is a relatively new strategy. And then obviously we have the capacity to revascularize those that have coronary artery disease. It's the most common cause of heart failure with either percutaneous techniques through the skin like angioplasty and stenting or bypass surgery when that's indicated. And at Saddleback, we actually have the capacity to perform off-pump bypass surgery, which is a little bit safer in some patient populations. Lastly, I would say we're looking to partner with some of the local tertiary care institutions so that we can be on the cutting edge. There are new therapies coming out with gene therapy and some stem cell-based therapies that we're very excited about participating in the development of. So that's a general overview of what we do. And the one thing I would add, and I'll quickly say this, is that we also have the setup to evaluate patients who have these therapies. We have a special pacemaker and arrhythmia clinic at Saddleback. That allows us to follow those who have these devices and optimize them. So that's a general overview of what we have in terms of therapeutic possibilities for this population of patients.

Deborah Howell (Host): I would say that's more than a handful of wonderful options. It sounds like mostly with a small surgery, because I'm assuming the pacemaker surgery is getting ever more patient friendly, am I right?

Ryland Melford III, MD: Certainly. Absolutely. We would consider it minimally invasive at precedent. Typically, a pacemaker patient goes home the morning after their implant.

Deborah Howell (Host): Is it done robotically or is it still done surgically by surgeon's hands?

Ryland Melford III, MD: So no, it's actually done for the most part by cardiologists now in the catheterization lab. And what the pacemaker generally involves, a quick anatomy lesson, is that wires are placed through the veins. So through a person's veins after they've been anesthetized and made comfortable. And then there's a small, and those wires are what we call electrodes, are then placed in the heart to perform the pacemaking or defibrillator function. And then there's just a very small battery or generator that's usually in the patient's upper chest. And so most people, and I'd say the great majority, tolerate these devices very well, you know, because they don't make noise typically, etc., etc. So it's not something that the patient, you know, notices other than the fact that, you know, they're able to go about their day with the reassurance that they have, you know, a sentinel there, if you will, to kind of keep an eye on things and make sure their heart works well.

Deborah Howell (Host): I'm so, so curious. I mean, it's such a wonderful thing that you're doing this already, but in the future, I would love for you to outline real quickly what some of the stem cell treatments might look like for a patient in the future.

Ryland Melford III, MD: That is a fantastic question. That is actually one of my specific clinical interests from the time that I was a fellow. So, really quickly. I mean, what we're looking at is, well, quickly, when a person has a heart attack and the heart muscle cells die, they do not have the capacity of some of the other cells in the body to regenerate. Okay, so a scar is left. And the goal with stem cell therapy and what we're hopeful for in the future is that we'll be able to find a mechanism to deliver premature cells, if you will. So a patient's premature cells that haven't differentiated into heart cells or nerve cells or skin cells yet and stimulate those cells to develop into a functioning element of heart muscle, a functioning syncytium that would replace the scar left by the heart attack or whatever other process, compromise the person's function. Now, we're not there yet, okay. Sort of very early in the clinical trials and development of trials and developmental trials, if you will, for this therapy. But it's very exciting. And, you know, I can't give you a time frame, but I can tell you that all of us in heart failure are... you know, incredibly interested in the possibilities for this therapy as well as gene therapy.

Deborah Howell (Host): And then maybe someday we won't have to call it failure. Maybe we can get that word out of there.

Ryland Melford III, MD: Yeah, that's something that I'd like to pioneer if I could be involved in because, yeah, it's a challenging word for patients. You know, when you hear failure, you know, the connotation of that word I think is, you know, both inappropriate and, you know, it scares people for a good reason.

Deborah Howell (Host): Replace it with challenge.

Ryland Melford III, MD: I like that.

Deborah Howell (Host): Well, we have just a couple minutes, but we could talk real briefly about gene therapy.

Ryland Melford III, MD: Sure. Well, you know, so gene therapy is really the evaluation for gene therapy is just beginning. The really quick example I can give you is with a gene called CIRCA-2. What we've identified is that patients who have heart failure have abnormal metabolism of calcium in their heart cells. Calcium is responsible for helping heart cells contract or function. The abnormal calcium, regulation if you will, within heart cells has been effectively modified in some mice models and some animal models using a specific gene that is involved in calcium metabolism, and injection of this gene has been has been shown to improve function in some populations so again we're sort of far away yep but we're getting closer.

Deborah Howell (Host): Wonderful. Thank you so much, Dr. Melford. Let's do a whole ‘nother show together on StemCell.

Ryland Melford III, MD: Great.

Deborah Howell (Host): Thanks so much for your time and your expertise today. We really appreciate it.

Ryland Melford III, MD: It's my pleasure. Thank you very much, Deborah.

Deborah Howell (Host): I'm Deborah Howell. Join us again next time as we explore another weekly dose of wellness brought to you by MemorialCare Health System. Have a great day.