Congestive heart failure clinic

Podcast transcript

INTRO
Welcome to Docs in a Pod presented by whelmed. Over the next half hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-host Dr. Tamika Perry and Carmenn Miles will share information to improve your health and well-being. And now here are Carmenn Miles and Dr. Tamika Perry.

CARMENN MILES
Hello and welcome, everybody, to this edition of Docs in a Pod presented by WellMed. I'm Carmenn Miles alongside our co-host today, Dr. Tamika Perry. If you happen to be listening to Docs in a Pod for the first time, you can catch episodes of this award winning podcast every Saturday on your favorite listening platform now including Amazon Music, audible, and iHeartRadio. You can also find us on the radio in several Texas markets. Each week we are here to tackle health and wellness topics, especially those that impact the senior community. Our goal really is to offer practical information on how we can all live healthier, happier lives and to help us better manage the chronic conditions that so many of us deal with. Thanks for listening in today. As I mentioned, our co-host today is the Dr. Tamika Perry. You can find Dr. Perry at WellMed at Redbird Square in Dallas, Texas, where she cares for her patients. She's an associate medical director, overseeing several large clinics in the Optum Care North Texas region. She's board certified in both family medicine and osteopathic treatment. Additionally, she earned a Master of Public Health from the University at North Texas Health Science Center. She says she was inspired to enter a career in medicine to help provide quality health care to the disenfranchised, and she's absolutely fulfilling what she set out to do at WellMed at Redbird Square. She enjoys working with families and communities as a whole and building relationships with her patients. Outside of medicine, she's a proud mother, and she travels the world every chance she gets. I'm so jealous of her travels. As of late, I think she's been taken up line dancing. That could be a rumor, but you'll set us straight, won't you, Dr. Perry?

DR. TAMIKA PERRY
No. It is definitely not a rumor. I've been on and off and on for a few years now. Now I still got two left feet, but it is fun and is good cardiovascular exercise, so I encourage everyone to do something that gives them some good cardio and may help prevent the topic that we're going to talk about today.

CARMENN MILES
Very good. Yeah, let's get into our topic. But before we go there, let's introduce our guest today. Our guest today is family nurse practitioner Stephanie Bruno. Nurse practitioner Bruno has 24 years of nursing experience, including 13 years as an advanced practice provider. She's passionate about improving the lives of her patients through high quality, evidence based care by building trusting relationships that support long term health and well-being. NP Bruno's diverse educational background gives her a unique perspective on the whole person and the factors that influence health. She earned a Bachelor of Arts in sociology from the University of Colorado Boulder, a Bachelor of Science in nursing from the University of Massachusetts Boston, and a Master of Science in Nursing from the UT Health Science Center at San Antonio. This combination of social sciences and advanced nursing practice really strengthens her commitment to patient centered care and addressing the social determinants of health. Since 2018, she's been a family nurse practitioner in the congestive heart failure clinic at specialist for health, in partnership with WellMed. In this role, she provides comprehensive care for patients with heart failure and other cardiovascular conditions. This year, NP Bruno was honored by the San Antonio Express newspaper as part of its Salute to Nurses program in recognition of her exceptional contributions to cardiology. This procedures award highlights her dedication to advancing cardiovascular care and her positive impact on the lives of her patients and the community. She's known for her clinical excellence, empathy, and collaborative approach. NP Bruno believes that the best care is delivered through teamwork, patient education, and shared decision making. Great culture calls. She says her mission is simple: To help every patient live a healthier life with confidence and dignity. I absolutely love that, NP Bruno, confidence and maintaining a sense of dignity makes a world of difference when dealing with medical conditions. I see this in my own family members. Welcome to the call, NP Bruno.

STEPHANIE BRUNO, NP
Thank you for having me.

CARMENN MILES
YouÕre welcome. Back when I was just a kid, I spent a few years at the San Antonio Express-News as a crime reporter. So, I'm happy to hear that they are still doing good things and recognizing people who are making a difference in the community and in their profession. So, congratulations again.

STEPHANIE BRUNO, NP
Thank you very much.

CARMENN MILES
Before we jump in, let's take a moment to welcome those who may have just joined us. You're listening to the award winning Docs in a Pod presented by WellMed. This podcast is available wherever you listen to your favorite podcasts. That list has recently expanded to Amazon Music, audible and iHeartRadio. I'm Carmenn Miles alongside co-host Dr. Tamika Perry at WellMed at Redbird Square in Dallas, Texas. We're chatting with our guest today, NP Stephanie Bruno at Specialist for Health Crockett Park Cardiology in San Antonio, Texas. We're so privileged to have you here with us today to chat about congestive heart failure. Whenever I hear that term, it just kind of feels a little bit like gloom and doom, but it's really not all that. Let's talk a little bit about medical professionals mean when they say congestive heart failure. It doesn't really mean that the heart has stopped working, correct?

STEPHANIE BRUNO, NP
No, not at all. It really is kind of a syndrome that we're talking about that's associated with a variety of symptoms, such as dyspnea, ankle swelling, orthopnea or patients may be having difficulty laying down because they can't breathe. It's a result of some sort of structural or abnormality in the heart that's causing it not to function appropriately. We do classify it in different ways. We are looking at the function of the heart where we are looking at what we call the ejection fraction, meaning how much blood is being pumped to the body over how much blood is left back in the heart. That's a ratio when we get a percentage from that. 60 to 65% would be a normal heart, and as that ejection fraction gets lower, we classify it either reduced ejection fraction meaning less than 40% or preserved ejection fraction more than 50%. Then we have that middle of the road in the 40% area that we call mildly reduced. So, we are kind of looking at that and that will guide our therapies for these patients.

DR. TAMIKA PERRY
A lot of people will say CHF runs in my family, but really, it's probably uncontrolled high blood pressure, coronary artery disease or maybe even something like Stephanie mentioned before, structurally wrong with your heart where it doesn't pump correctly. It's a very important, distinct notification. She did an excellent job of explaining that.

STEPHANIE BRUNO, NP
Yes. I'll also add to that Dr. Perry, that yes, those are the most common reasons that you brought up that we see these heart failure patients is for uncontrolled hypertension over a long period of time, coronary artery disease, arrhythmias such as atrial fibrillation or valvular heart disease.

DR. TAMIKA PERRY
Exactly. It leads to congestive heart failure. So, you just don't wake up and say at 25 years old, I have CHF. That's probably a congenital, like you were born with something wrong with your heart, and then we know by that time. Most people, it's later in life because this is a slow going process. When you become short of breath or you use the fancy term dyspnea, which is shortness of breath. What is this shortness of breath from? Is it from your heart. Is it from your lungs. If itÕs it from your heart, is it because of years of, I don't need my blood pressure medicine because I feel just fine.

STEPHANIE BRUNO, NP
Right.

DR. TAMIKA PERRY
That's because untreated high blood pressure leads to this.

STEPHANIE BRUNO, NP
Exactly.

CARMENN MILES
I get the heart failure piece of it. I'm trying to figure out where the congestive comes into play. Does that mean there's some type of backup when it comes to fluid, or the pumping of oxygen rich blood to the organs? Tell me where that comes in.

STEPHANIE BRUNO, NP
Great question. Heart failure and congestive heart failure are two different things. The congestion part comes when the patient is decompensated. Like you said, Carmenn, fluid will be backing up into the lungs or the body, and that's presenting itself as worsening shortness of breath than their baseline and worsening lower extremity edema, so on and so forth. We can see certain things on physical exam that are indicating this congestive heart failure. We'll hear crackling in the lungs. The veins in the neck will be distended. We also can get some other data with labs such as what we call the brain natriuretic peptide. That's a hormone that's released by the heart when patients are in congestive heart failure. That's measurable, and it will tend to be markedly elevated if patients are in that situation. A chest x-ray we will be looking at as well.

DR. TAMIKA PERRY
Yes. I like that you've brought up the BMP because a lot of times with patients, they'll have symptoms like shortness of breath and swelling. This may be prior to diagnosis in your in the office. Of course, I don't have an echo in my office as a primary care provider, but I'll say, let's do a blood test, and theyÕll say, there's a blood test that can tell me about my heart? There absolutely is. Even though the name is kind of oxymoronic, the brain natriuretic peptide is actually made by your heart. So, when that's elevated, that's a sign that nurse practitioner Bruno and I used to say, hey, you know what, friend? We need to jump on this because it looks like you're in heart failure.

STEPHANIE BRUNO, NP
I love that you're checking that in the primary care world, Dr. Perry, and then hopefully sending them over to our clinic once you identify these patients because then we can follow up with the diagnostic workup of doing that echocardiogram and seeing what's going on with the heart structurally and guiding their care.

DR. TAMIKA PERRY
Exactly. What can we do to even not get to this point now? What can we do to prevent heart failure from coming?

STEPHANIE BRUNO, NP
A lot of this is really based on lifestyle. Things like type 2 diabetes, obesity, hypertension, the things that we see under the metabolic syndrome umbrella. So, trying to keep that body mass index less than 30, the hemoglobin A1C less than 7%. You really want to be keeping your blood pressure less than 130 over 80, ideally 120 over 70. Then exercising routinely. That's beneficial and staying away from our heart failure clinic if you're exercising 30 to 60 minutes a day. Some sort of cardiovascular, running, walking, swimming, line dancing. Whatever it is that you choose to do, but something every day.

CARMENN MILES
Very good. It's time for us to take just a quick break, but please stay with us as we continue this great healthcare discussion on congestive heart failure. You're listening to Docs in a Pod, presented by WellMed. We'll be right back.

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CARMENN MILES
We're back on Docs in a Pod. I'm your host, Carmenn Miles, along with our resident co-host, Dr. Tamika Perry at WellMed at Redbird Square, and our guest today amp Stephanie Bruno at Specialist for Health Crockett Park Cardiology in San Antonio, Texas, and a recent recipient of the San Antonio Express newspaper Salute to Nurses, a very prestigious award highlighting her dedication to advancing cardiovascular care. NP Bruno, I want to discuss the symptoms. I imagine many symptoms are overlooked or ignored, or maybe even dismissed because maybe patients think, oh, I'm just tired. Or maybe I ate too much salt and that's causing the swelling. Or maybe I'm just getting too old to do some of the things that I used to do. So, let's talk about some of the symptoms. I'm curious to know, do the symptoms associated with CHF come on all at once, or do the symptoms happen over time?

STEPHANIE BRUNO, NP
They typically happen over time. They can happen suddenly, but most commonly it is a progression. Like you said, patients just tend to chalk it up to I'm old. I'm not able to do what I used to do as far as getting shorter breath with activity, but I highly encourage patients to discuss that with their primary care doctor, especially if they have issues with hypertension. Like I had described earlier in the talk, they're diabetic, overweight. All these factors can contribute to having more risk of developing heart failure. So, it's really important that that workup gets done. Then once we identify that a patient does have heart failure through an echocardiogram and or ultrasound of the heart, then we are talking about trying to get you on what we call guideline directed medical therapy. And that is really based on evidence through the American College of Cardiology. We use that as a resource. They provide us with guidelines that we look at. The last time that they were updated was in 2022. We're talking about usually four medications that we try to get patients on that combat the compensatory mechanisms that can happen when you do have heart failure. So, we're talking about Ace inhibitors, beta blockers, aldosterone antagonists, and now we have Sglt2 inhibitors, which were really for diabetes in the beginning, but now we have realized that they are very beneficial in slowing down the trajectory of heart failure. So, we use all these four drugs, and it can be a complicated, and that's why we're here at heart failure clinic for patients to understand the need for these medications. A lot of them think that these medicines are for blood pressure, and they don't understand if their blood pressure is low, why do they need to take these medications. So, that's what we do in our clinic is to spend the time educating patients on how these medications work and how they're going to be beneficial for improving their outcomes.

DR. TAMIKA PERRY
Right. We want to ensure that every patient, and particularly heart failure patients, because that's what we're talking about now, have not only extended your life but extend the quality of your life. Good years. Not years in the hospital, not years with exacerbations of shortness of breath, lower extremity edema, feeling tired all the time. Being fatigue is really a one of the hallmarks, especially closer to end stage heart failure. So, we want to do our best to prevent that. A really short anecdotal story, when I was a resident, many, many, many, many moons ago, there was a gentleman who came in the ER, he would actually run every day, but he couldn't run this particular morning because he was short of breath and coughing and he was swelling a little bit. He thought he had a cold. So, when he came into the ER, we hooked him up to all the monitors stuff, blood pressure was sky high and of course, he had CHF. I said, sir, why havenÕt you been taking your blood pressure medicine? He says, oh, I got high blood pressure? He said, somebody told me that about 20 years ago, but I don't want to take those medicines because I just thought they wanted my co-pay. So, I was just going to run every day, which is great. Running is great, but he needed something a little bit more aggressive to treat that blood pressure just besides running. He needed to take his medication. So, now we're behind the eight ball because as per him, up until recently, he didn't feel anything. He felt just fine, but now he has heart failure. Now he can feel it. His ejection fraction, which Stephanie talked about earlier, at this point was 25%. At that time, many, many, many, many moons ago, when I was a resident, his life expectancy was less than six months. He also had some other stuff going on he was unaware of. I think he died in three months. This is a gentleman who ran every day. He still smoked. He didn't take his medicine. He did a few other things, and he thought that, I'm just fine. I just have a cold now. This is a process that had been going on for a long time. So, some of his shortness of breath he kind of chalked up to well, I'm smoking, but you know my running is going to negate it. So, this is the importance of the general population having a relationship with your primary care provider, having a relationship with your nurse practitioner. If you have high blood pressure in these symptoms and your BNP is fine, when I send you to go see nurse practitioner Stephanie Bruno, please, please go because I need to see what that ejection fraction is. We need to put you on guideline directed medical therapy, because Stephanie and I would rather you be on four medicines for your heart failure. You live a good, productive life because if you're in a wood box, you don't have to worry about any medicines.

CARMENN MILES
That's right.

STEPHANIE BRUNO, NP
Absolutely. That is a topic I talk about at length with my patients, because sometimes patients come to me and they aren't symptomatic. We just noticed on the echocardiogram that they've got issues. So, I really highlight that this can get worse if we don't intervene now with these medications to slow down the progression. I always see it as a team effort. That's how I try to frame it with my patients. Trying to establish a sense of trust. By the time they get to me, they've been through quite a bit, so they're very reluctant and hesitant to make medication changes. So, I really try to get to know the patient through a holistic approach. Who are they? What are their values? What's important to them? That really kind of helps me circle back to these social determinants of health. A lot of times we just say, they're noncompliant. They don't take their medicine. But I dig a little deeper and try to figure out what is really going on. Is it insurance issues? Are they having a hard time getting to their doctor's appointments? Are there family issues? It could be a variety of things that are barriers to these patients.

DR. TAMIKA PERRY
I'm glad you brought that up because for the guideline directed medical therapy, all the medicines except for the Sglts are pretty inexpensive. Now the Sglts are getting a little bit more inexpensive, but you got to let your doctor know, because where there's a will, there's a way, right? So, a lot of times the manufacturers will have programs. Your insurance may have a program embedded in it. You may be able to apply for the low income subsidy program through Medicare to help you get these drugs cheaper. But if we don't know, we can't help you. So, let us know these things, especially if cost is a barrier, because we'll try to find a way around that so you can live, as my daughter says, live your best life.

STEPHANIE BRUNO, NP
Yes. We have a whole troupe of friends on our team that that work tirelessly to keep these patients on guideline directed medical therapy, accessing all those different programs that can help with financial assistance. So, it does take a village. I work with a great group of cardiologists. We have RNs. We plug in to palliative care. There are all kinds of people involved with the care of these patients. It's very complex.

DR. TAMIKA PERRY
Once you have a diagnosis of heart failure, our goal, like Stephanie said, heart failure and congestive heart failure, we used to use them synonymously, but they're really two different things. Are you have an exacerbation? Is your diagnosis flaring up? That's what the congestive part is. We don't want you to have the flare up. So, that's why we want you to exercise. Low sodium diet. Low fat diet. Keep your sugar right. Take your guideline directed medical therapy. This is what keeps you as even keel as possible, so once again, the quality of your life is what it is supposed to be. We don't want you to be sitting at home and you're short of breath in your recliner. Nope. That's not our goal in at least a little bit. Our goal is to make sure that you can go out and play with your grandkids. You can walk in the mall. You can have lunch with your girlfriends. Whatever your pleasure center is, you can do it. We want you to be able to do whatever activities, whatever you do in your life that is conducive for you without this gloom of CHF over your head, because Stephanie and I have taken care of it peripherally.

STEPHANIE BRUNO, NP
Yes. That can be a challenge because patients feeling chronically short of breath, that can make their quality of life very low, and it's hard for patients. So, we do have a questionnaire that we use in our clinic trying to identify how is this syndrome affecting all aspects of your life. As far as your physical activity, are you going out with friends and family? Do you feel like a burden? So on and so forth. Just to gauge where the patient is at and tweaking our therapies to have better responses on that quality life questionnaire.

DR. TAMIKA PERRY
I love that questionnaire. YouÕve just given me an idea. I'm going to start to implement that into my office, too, because like you said earlier, what is important to you?

STEPHANIE BRUNO, NP
Yes.

DR. TAMIKA PERRY
What is the quality of your life? What can Stephanie and I do to make sure that you live life the way you need to live life? That is the whole point of this. Not just pushing drugs, not just trying to make you join a line dance class, but if you do decide to it is every Wednesday here in Dallas. Not any of that. It is what is important to you. So, let us do medically what we can to make sure that you can do what's important to you.

STEPHANIE BRUNO, NP
Yep.

CARMENN MILES
As we begin closing, I just want to reiterate some of the things that you both encourage patients to do. What are some best habits? Like reducing some of the sodium, the intake of sodium. Taking your medications consistently. What are some other things? Quit smoking, we know that. Stop the smoking. If you're still smoking, stop smoking, please.

STEPHANIE BRUNO, NP
Losing weight. I know that's easier said than done, but now we have these GLP-1Õs that are showing some cardiovascular benefit too, with the latest studies. Things like that. Like I had mentioned before, keeping your diabetes under control, your cholesterol panel needs to be in range. The blood pressure control is super important.

CARMENN MILES
Very good. We're just about out of time. Thank you both for taking time to share this heart to heart conversation with us today on congestive heart failure. CHF doesn't mean that the heart is stopped working. It means that the heart isn't quite pumping as efficiently as it should. But the great news is early recognition of symptoms can lead to earlier treatment and better outcomes. With the right medical guidance, as you've heard here today, medication and healthy habits, many people live full and active lives with CHF. Thank you, Dr. Perry and NP Bruno. Remember, when it comes to heart health, small changes today can have a huge impact on tomorrow. Thank you all for listening to Docs in a Pod presented by WellMed. Until next time, stay well.

OUTRO
Executive producer for Docs in a Pod is Dan Calderon. The producer is Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed. Be sure and listen next week to Docs in a Pod presented by WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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