A Conversation About Heart Failure With Milton Packer And Richard Lehman

Milton Packer and Richard Lehman are both 66 years of age. Packer has been leading major heart failure clinical trials for decades. Lehman is a retired UK GP who writes a blog for the BMJ website. The two have agreed to answer questions and participate in a discussion about their different ideas and perspectives about heart failure. This is the first installment of a series. In future episodes I will ask Packer and Lehman to elaborate on the implications of their different philosophies.

Question: What do doctors get wrong about heart failure? What are the biggest and most important mistakes they make when dealing with heart failure patients? What should be the goal of treatment?

Milton Packer:

There are two types of mistakes that physicians commonly make. Interestingly, they are almost polar opposites of each other.

On the one hand, many physicians erroneously think that it is possible for patients with chronic heart failure and a reduced ejection fraction to be stable and do well. In truth, no patient with chronic heart failure is stable; they all have a progressive disease that requires aggressive treatment. In many cases, the evidence for instability is worsening symptoms, but in many others, the disease progresses silently until the patient experiences sudden death. I have heard physicians say that they think that sudden death in a patient with heart failure is a good thing because it stops suffering or because it is a peaceful but unavoidable occurrence; they mistakenly think of it as a new arrhythmic or ischemic event. That is very unfortunate. Most sudden deaths in patients with chronic heart failure are directly related to progression of the underlying disease, and they are largely preventable. Every death in a patient with heart failure is a regrettable occurrence, but fortunately, most deaths can be delayed for long periods of time.

Milton Packer

At the same time and by contrast, many physicians erroneously think that heart failure is simply part of the natural way of dying. They see an elderly patient who is suffering, and they think this is an acceptable way that life can end. They think that heart failure is by its very nature an inexorable disease that is rapidly fatal, and that prolonging life means the prolongation of suffering. This is very far from the truth. In the 21st century, patients with chronic heart failure generally show slow progression over a period of 10-15 years. Although many patients are elderly, the disease does not start late in life; it generally begins around the age of 60-65, and the treatments that we have can add many years to a patient’s lifespan. Most importantly, these are not added years of suffering. The drugs that prolong life also have significant beneficial effects on symptoms and quality of life. When we are successful (and we often are), most outpatients with heart failure are mildly symptomatic, and they can realistically look forward to many additional years of life experiences.

The key to communicating with a patient with chronic heart failure is to tell them that they have a really serious but manageable disease and that we can relieve suffering and prolong life. But you also need to tell them that treating heart failure successfully is really complicated. Most patients require at least four drugs used simultaneously and taken for very long periods of time, often in combination with devices. The conquest of heart failure is achievable, but it requires a great deal of work on the part of both the patient and the physician. Patients need to be told that they can really impact their disease, and they need to find a physician who is willing to make the commitment to do so. Too many patients are told either that they are doing well or there is nothing that can be done. Very few patients are receiving the best possible treatments that we have to provide.

Richard Lehman:

Thanks Larry for these great questions which set our conversation on a very broad path. That suits me because I have always been a complete generalist, and the heart failure patients I have seen have always been people who depended on me for all aspects of their care.

What do doctors get wrong about heart failure?

Richard Lehman

It starts with the label. The conversation has to begin by settling the patient’s mind at rest that this horrible expression does not denote imminent death or some “failure” on their part or even their heart’s. Years ago I argued in a BMJ editorial for “impairment” rather than failure, but with little effect. [Editor’s note: For more on this subject CardioBrief readers might be interested in reading a guest blog post from 2010 by Mary Knudson: Heart Failure Death Statistics: Don’t Believe What You Read On The Internet.]

What are the biggest and most important mistakes they make when dealing with heart failure patients?

At the beginning I think a frequent mistake is information overload. Test results and therapeutic possibilities can be set out at length to the exclusion of eliciting the patient’s level of understanding and their own goals for treatment. Another mistake may be to focus on their heart failure without consideration of their other health problems. Subsequently it may consist of ignoring mundane but vital aspects of their lives while pursuing biochemical values, “objective” measures of function, and particular target drug levels. In the end stage, it may consist of piling on medication and inserting devices rather than having difficult conversations about the aims of care and the limitations of what is available.

What should be the goal of treatment?

I think it should be the sharing of a difficult journey in the kindest and most effective way possible, constantly informed both by the evidence and by the wishes of each individual.