Welcome to the HFSA Mended Hearts Patient Education webinar on Managing Heart Failure and Diabetes. I'm Patrice Guzman, the Director of Science Research and Patients for the HFSA. We would like today's webinar to be interactive, and as such, we encourage you to submit questions to our presenter using the questions tab on the left side of your screen. Please feel free to submit your questions at any time. The question and answer portion of the program will immediately follow the presentation. We would also like to point out a great feature for those who wish to take notes during the presentation. When you click on the notes tab on the right side of the screen, you'll see a white text box where you can take notes on today's webinar. These notes will be emailed to you automatically at the end of the presentation. Now, I would like to introduce today's speaker, Dr. Panrithi Atagam, is a tenured associate professor at the University of South Florida College of Nursing. She is an acute care nurse practitioner who shares her expertise with her students and the community in which she lives. Her research is focused on auditory cognitive training and technology-based interventions for patients with heart failure to improve self-care practices, quality of life, and thus reduce hospital readmission rates. As a PI, she has received funding from Florida High Tech Corridor, the C.S. Draper Laboratory, and National Science Foundation Innovation Corps, and designed a mobile phone application called HeartMap to improve self-care of patients with heart failure at home. Currently, she's receiving funding from the National Institute of Health, Small Business Innovation Research, and a grant to test HeartMap with cognitive training as a device ready for commercialization. She's a fellow of the Heart Failure Society of America and also a fellow of the American Association of Nurse Practitioners. I would not like to hand the presentation over, and we will get started. Thank you. Thank you, Patrice, for the warm introduction. I'm really thrilled to be part of this webinar because as a patient myself having diabetes, after the age of 60, I had a heart attack, so I'm taking care of myself to prevent heart failure in my lifetime. So I'm really thrilled what every one of you can do and not worry that I have diabetes, am I going to develop heart failure? So with that, today's webinar, I'm going to really talk about the impact of diabetes on heart failure, how do you manage diabetes and heart failure at the same time, and how do you communicate with the heart failure team while caring for your diabetic and heart failure? So most commonly, I have come across as a provider is, can diabetes cause heart disease? So heart failure actually is a condition which we call it as being under-recognized or misdiagnosed. So research supports that diabetes can increase the risk of cardiovascular disease by two to three-fold. Recently, evidence also supports the incidence of type 2 diabetes have increased by 83%, particularly very high among males compared to females. And the risk of heart disease due to diabetes also has increased in the late 20th century by almost 8%. And 68% of people aged 65 or older could die from some form of heart disease compared to those who don't have diabetes. So with that little bit of introduction, most common reason why people with diabetes get heart attack or cardiovascular disease is due to diabetes, nerve damage can interfere with pain signals. If you have diabetes, you know that you get neuropathy in your leg, your nerves get affected in your eyes, that you can develop diabetic retinopathy. So same way, the nerve damage interfere with the pain signals in the body, in your heart, and most people with diabetes don't have the severe chest pain which normal people with when they get heart attack, they may get indigestion or heartburn without any just discomfort. And we call this silent heart attack in diabetes. Many people don't even realize. We have seen them had a heart attack before, and we only identify them based on testing. So that's why it is higher risk for patients with diabetes to develop heart attack or die of heart disease because they don't seek treatment immediately because they think that it's just indigestion. The other pressing questions we as providers are asked by patients is, can diabetes cause heart failure or can heart failure cause diabetes? So heart failure actually is not the consequences of diabetes. But as I mentioned earlier, diabetes is independently associated with the risk of developing heart failure, similar to how it increases the risk of having a heart attack or other form of heart disease. We say that almost two-fold increased incidence and almost about five-fold increased incidence of heart failure in diabetic women, five-fold. So that's why I said, as a woman with a diabetic who had a heart attack, I take every precaution to make sure that I don't develop heart failure. So this topic is very dear and near to me. And the other thing what we needed to consider is, as such, heart failure has a much poorer prognosis compared to diabetes, because diabetes is a slow killer. But when you develop heart failure, it can kill you faster. And that is why for diabetes patients, both, they develop either reduced ejection fraction, that means your pumping function is reduced, or your pumping function is preserved. You get a stiff heart. They both can increase the risk of dying or morbid problems. So to tell you in nutshell, what is the impact of diabetes and heart failure on life? The prevalence of diabetes among patients with heart failure has increased by 360% compared to only 54% among general population. So this is a very high impact. And both heart failure and diabetic patients, if you have both the diseases together, the survival rate is less than 10 years. And people who have a heart attack and diabetes have three times the risk of developing heart failure compared to those who had no diabetes. No wonder I am worried, right? So that is the important thing that we need to do everything to take care at the time so that you don't develop heart failure if you have a heart attack or if you have diabetes together. And that is why the impact of diabetes and heart failure together is much greater in life for anyone having both the conditions. So here is just an illustration to show you, if you look at it here, this is a death chart or mortality chart, which was presented and you can see here, CHF is the top and the red line, which is 75 or above, people with diabetic and heart failure at the age of 75, they die more. And if you take a look at it between 65 and 74, they do die of heart failure, but their heart attack rate is very high. So this is just to give you a pictorial understanding on how important it is to understand the impact of both the diseases in one's life. So what changes take place in the heart if you have diabetes? So this picture actually gives you an impression. When you have high blood glucose level, it increases the deposit of fatty acid inside the blood lining. So if you see, this is a clean lining of the blood vessels, this is cut open for you. But whereas if you have diabetes, the glucose deposits here and that can track blood clots. And that is what causes heart attack. And also in diabetic patients, the deposit also can happen in your heart muscles. So if you see here, your heart muscles get thicker from all the fatty deposits. It can also get dilated over time. So this is what we call it as a stiff heart or preserved ejection fraction. The heart is pumping enough blood, but it's not holding enough because the chamber has a smaller amount it can hold. So it can happen both ways. And that's what changes happen in patients with diabetes in the heart. So understanding the symptoms of heart failure and diabetes is very important. I always tell my patients, listen to your body before it screams at you. Because if you listen to the symptoms, the early symptoms like weight gain, swelling in your legs or abdomen, shortness of breath, some people will just have fatigue, bloating in your stomach or an early cough. So these are the early symptoms of heart failure. So if you ignore this, then it starts to scream at you. You are bloated and you can't catch breath even sitting up. So we don't want you to wait until your body screams at you. Want you to listen to your body with early symptoms. Same way with diabetes. If your blood sugar is high, you will know you are urinating very often. You are feeling very thirsty, hungry. And if your sugar is low, the common symptoms is dizziness, sweaty, shaky. We want you to manage these symptoms early before it screams at you. This is a good picture that I found. And I said, this is what every patient who has diabetes and heart failure should know. Listen to your own body. What is different? What has changed in you today before it starts to scream at you? And we as providers often tell you, manage your diabetes and heart failure symptoms at home. Most hospitals or most doctor's offices started giving this traffic light system. We call it a green, yellow, red, just like your traffic light. It's available for almost all disease conditions. So we also provide these for all of our patients with heart failure. This is available. I'll show you where you can find it if your doctor has not given this traffic light system for you. So it will tell you if you monitor your symptoms every day. If you are stable, it will tell you you are in green zone. We want you to get to the doctor and get medical help with mild decline to yellow zone. Don't wait until your symptoms are worse and you are in the red zone. That means your body is screaming when you are in red zone. We want you to listen to your body as soon as it declines a little bit, goes into the yellow zone. So this is what is very, very important when you're caring for yourself. So I have here two technologies that are being used. One is by Heart Failure Society of America, which is Heart Failure Health Storyline, which is an app. And there are also several apps under development, like one I am developing, which is still under testing phase. But HFSA has released this app, which is available on the market for you to download. It helps you to manage your symptoms and understand and listen to your body as soon as you decline to the yellow zone. And they are also American Heart Association has another one available. So I would encourage if you have heart failure to download this app in your phone. This will really help you to manage your symptoms and listen to your body as soon as mild decline in your symptoms. So you can approach your doctors and get the help you need at an early stage before your body screams at you. Same way, there are technologies available for self-management. Yeah, I have put it here. So again, traffic light system. If you're A1c, which is the average number of blood sugar over the three-month period. If you have your blood sugar is less than seven, you have a good control of your blood sugar. If it is more than seven, but around eight, it's be careful. You still need to take care of yourself and, you know, need to follow your diet and exercise so that you can bring it down. If it is more than eight, that means it's red. It's screaming at you. You are in trouble. So these are very important. And there are glucose bodies. There are food trackers which count your carbohydrate, how much sugary item you have eaten. So these apps are available for you to download. You know, we used to think that we, I think 2010, there were 50% of older adults above 65 had a telephone or had a mobile phone. Now, the Pew Internet Survey says 96% of people have some form of a mobile phone. And these apps are available for Android phone, Apple phone, or Windows mobile, that you can download for a better management of your diabetes, as well as your heart failure. I'm a big proponent. I tell my patients to download these apps and they use them. So here is another important thing. Food choices. Diabetic and heart failure. Very important about food choice. For diabetic, you are not going to eat a lot of sugar. And when I was diagnosed, I love bread. So it's difficult for you to give up bread. And heart failure, we tell you to reduce the salt. Take away the salt shaker from your table. Don't add extra salt when you're cooking. But we know salt gives you the taste. So it's very important how to have a good way of adjusting your diet. So my next slide actually gives you... I think it's the next slide. So I'll show you that. So both of these conditions need dietary modification. They are both different. One calls for low carbohydrate and heart failure calls for salt and water intake. But avoid starchy carbohydrates. So you can eat pasta, but you can eat whole grain pasta so that it lasts long, digests slow, and it brings down your blood sugar. And always, always read labels for sodium content. I will tell my patients, avoid canned food. If you have to use canned food because you're not able to cook, then always read your sodium and carbohydrate content, what you are buying. And avoid a nutritional supplement in heart failure. But we always tell our diabetic patients, glycerin is a good supplement, which is good in protein, no salt there, but it maintains a steady carbohydrate in diabetes. So you need to talk to a diabetic nutritionist to get what you can eat. There are a lot of cooking advices available, even tips available, what you can eat, what you can't eat at HFSA website and American Heart website. Follow those. Log into those websites and get to know what you can eat and what you can't eat. Because that is very important for the care of your patients. The other thing is exercise. My patients sometimes with heart failure say, I can't catch my breath. I can only walk a few steps. Or, you know, once when you start to do it, start slow, but do it every day. But that's why I put this one, like laying down and stretching your leg, using a rubber band and stretching, holding up. These can be done at home. You don't have to go out in the sun that, oh, this Florida weather is too hot. I've heard my patients in Florida tell me it's too hot in summer. I can go out. You don't need to go out. You can do simple exercises at home. That's going to burn your sugar as well as help your heart. Because any muscle that is not exercised, including your heart, there is no assumption it's getting weaker. So you need to exercise and you have to balance your exercise. Because if you exercise too much, your blood sugar may go down so much that you get hypoglycemia. So that is why you need to have a balance of doing some simple exercises, like stretching and doing it at home so that you can still exercise your body. Because as I said, always remember your muscle that is not exercised, gets weaker and there is no assumption for your heart. There is also technology available that tracks your physical activities and food choices. I always tell my patients to use MyFitnessPal because I myself use this app called MyFitnessPal. This gives you not only the calorie intake, you can just pick where you ate. Okay, you went to a restaurant and you ate. And most often all of these restaurant foods, they provide what the calorie, how much protein, how much salt, how much carbs. It gives you so that if you have to go out today with your friends to eat, you know how much calorie you ate. So you may be able to adjust your next meal. So that keeps and it also provides how much salt you ate on that particular day. So some apps are really good that it provides you information, keeps you track of how much calorie you burned, how much carbohydrate you ate, how much salt was your intake. And by the time you come to the dinner time, it will say, you have already maxed out your carbohydrate. So eat some protein. It gives you the feedback. So you know, oh, I already ate carbohydrate. So let me eat just a piece of meat so that I'll have more protein. So that kind of a feedback is important, which offers you food choices. And I put this variable here because I've seen many of my patients using Garmin or Fitbit because that also helps to track your food as well as your exercise, which will help you to keep track of how you are doing, performing in your activities. Smoking is very important for both diabetic and heart failure. It changes how body processes and regulate sugar. It increases the risk of diabetic by 30 to 40% compared to a non-smoker. Smokers also have an increased risk for heart attack, which results in heart failure because heart failure is the end stage of all heart conditions. And smoking amplifies or increases both the conditions. And I always tell my patients, never too late to quit smoking. And CDC recommends technology, and this is from CDC. It's called a quit guide to help quit smoking. And there are many other apps available, but I am a big proponent of the recommendation by CDC, but it's a quit guide. How can I quit? So how can you stop the craving? So which is important? Smoking is very important for both diabetic and heart failure. And understanding diabetic and heart failure management. Both heart failure and diabetics have poor prognosis. And heart failure has to be the priority for treatment in patients presenting with both conditions. As I mentioned earlier, diabetes is considered a slow killer, but heart failure kills someone very soon. And that is why it's important if you have diabetic and heart failure, you should be managed by a heart failure team. The diabetes also must be managed by a heart failure team in consultation with an endocrinologist, not individually. So here I'm just going to give you a few tips on medications which we use for heart failure can also help a diabetic patient and some medications that you should avoid because both conditions need complex medication management. Medications that treat heart failure so far has no adverse events reported rather than some, because most often it prevents some complications due to diabetes. For example, ACE inhibitor, which is commonly called as lisinopril or any medications that ends with pril, lisinopril, bisopril, or whatever pril is, that are ACE. And ARV, which is a statin, erbostatin, or atorvastatin, not erbostatin, I'm sorry, valsartan, sartan. So those are ARVs. So these two medications help not only to prevent remodeling of heart in heart failure, remodeling in the sense, prevent worsening of the heart muscle or stretching of the heart muscle in heart failure, it can also help with diabetes because it helps the basal membrane inside the blood vessels so that it can help patients with diabetes. And the combination of succubitrol or valsartan, which is commonly called as Entresto, which is recently released a couple of years ago, is shown to reduce death and hospitalization in heart failure, also showed benefit in patients with diabetes. So in nutshell, there are not much negative effects of some medications that are used in heart failure, some except diuretics, which can decrease glucose intolerance. So patients with diuretics may need an extra little more dosage of insulin or your medication instead of 500, you may need a 750 milligram of metformin. So little extra dose because it decreases that glucose tolerance. Other than that, most of the heart failure medications have no negative effects on a patient's body or with the diabetic. So beta blocker, which is the metroprolol or bisoprolol. These are medications that are given for patients with heart failure who have reduced ejection fraction or preserved ejection fraction. They provide similar benefit for people with or without heart failure. It reduces the strain in the heart as well as the reduced strain of diabetes. And if the kidney function is decreased, which is a common complication of diabetes that is not controlled, some medications may not be able to tolerate. So you need to talk to your cardiologist and your endocrinologist. And that is why if you have diabetes and heart failure, you need to protect your heart as well as take care of the diabetes before other organs, including your kidneys, your liver, your nervous system get affected. Because if these systems get affected, some of the medications will have negative effect. And they may need, the dosage may need to be adjusted. And that's why regular follow-up with your doctors are necessary. And some glucose-lowering drugs could cause worsening heart failure. And that needs to be avoided. So here I put a warning. Usually, metformin is safe and effective. But if it's already starting to affect your kidney function, you may need to rethink. And your doctor may say, your kidney is getting affected. You may need to go on insulin. And sulfonylurea, glimepiride, this can also increase the risk of heart failure. We try to tell our patients if they are on these drugs that we tell them to avoid it. And precoce or acrobose can also increase the risk of heart failure three times. And Actos, Avandia, or Avandamid, these are actually taken off of the market because it was contraindicated because it causes salt and water retention and increase the incidence of heart failure. And recently, Genuvia or Cetagliptin, there is lack of data on this, but I take this for my diabetics and for the past six years, and I have been doing well. My A1C is 5.7. So this is what you need to do. What works for your body? So work with your doctors and listen to your body. What medicine works for you to control your diabetes? That's what you need to work on. And the other medications like Baida, Victosa, they can cause pancreatic cancer. And so it needs cardiology approval if you need to take them. So just because your endocrinologist say that, oh, you may be able to take Baida or Victosa and you see the ad in the TV, don't just start taking it. Get your cardiology approval because you may be at risk, but your cardiology needs to follow up on that. So make sure that some of these medications, if you're on or if you're started on, you need to make sure that you have your cardiology approval to take these medications and you are able to tolerate without any complications. The new oral drug that is to manage diabetes is Empagliferin or Giardia. You may have seen the ad, now you see it very often in the TV. This has shown to reduce risk of cardiovascular disease by 38%. It also reduced hospitalizations in heart failure patients by 35%. It also decreases sodium retention and fluid volume. Unlike the other medications I showed you that it can cause salt and water retention, which is against the heart failure. So you can increase the incidence of heart failure. This one lowers it. So this is a good medication. It also reduce weight and blood pressure, which goes hand in hand with diabetes and heart failure. So if you like, you can talk to your cardiologist about this. And in collaboration with your endocrinologist, your cardiologist may be able to give you a prescription for that. And if your kidney is affected and if you are not able to tolerate your oral medications, you may be placed on insulin. And just a brief information about insulin. Insulin, we have short acting and long acting insulin for better control of your sugar. But this can have significant sodium retention. So you need to talk, you need to be very careful. Even if it is not retaining salt, it also increases weight for people. So it has some adverse effects. So you need to really work with your doctors in adjusting your dose. And you need to be constantly supervised by your cardiologist and if you are started on insulin, you may need to adjust your diuretic dose because of the sodium retention and fluid retention. And so you need to be very careful about that. The other important key things that anyone with a diabetic and heart failure should remember is other comorbid conditions that comes as a package when you have both the conditions. Most often people with diabetics have high blood pressure, high cholesterol. And if you are also a smoker, you may have COPD or lung disease. And most often because of obesity, people develop sleep apnea. And as a complication of diabetes, you may develop kidney disease, arthritis, muscle pain. And with these, just these two conditions also increases depression and anxiety. And that is why it is important that you need to follow up with the cardiologist who can really manage this complex condition. And the other thing is, do you know your diabetic ABCs? A, for your A1C test, B, your blood pressure, C, for cholesterol, F, for stopping smoking. Now I will add to this A for A1C, B for blood pressure, C for not only cholesterol, any comorbid conditions or other associated conditions. Yes, for stopping smoking, but also symptom management for both conditions. That is the key to understand both diabetic and heart failure. One slide on advanced therapies for heart failure, CRT, which is a two-lead pacemaker or single-lead pacemaker, or implantable cardiac devices. And if these don't work, you will need ventricular assist device, which is a mechanical circulatory support, or heart failure, heart transplant. But if you are a candidate for advanced therapies, you need to work with the cardiology team to see which one you qualify for if you are a candidate for any of this. So you need to work with not just a cardiologist, a team that you need to work with to see if you qualify for any of these advanced therapies. Because if heart failure gets worsened, you need these advanced therapies. But being diabetic, we will always say that your diabetic needs to be controlled if you need to go for these advanced therapies, because diabetes also is prone to increase the infection rate. So we always want you to work with the team, including social worker, nurses, pharmacists, so that you can be determined if you are eligible for any of the advanced therapies for heart failure. The key thing, the next one, which is very, very important, is communication with your team. You need to have regular follow-up with your heart failure team and endocrinologist. You need to have regular echocardiogram, have to have a regular cholesterol level check, because often, even if your cholesterol level is normal, if you have diabetes and heart failure, we like to place our patients on a low dose of statin, which is like Lipitor, Atorvastatin, or Simvastatin. Like I said that I had a heart attack. My cholesterol level was normal when I had my heart attack, but I take a 10 milligram of Lipitor just to prevent, because the cholesterol medications not only lowers the bad cholesterol, it prevents inflammation within the blood lining. You remember I showed you a picture how the fatty acids get built up inside the lumen of the blood vessel? If the medications which lowers cholesterol prevent the fatty buildup, even when your cholesterol is normal. So your doctor may say that you need to take this medication. And you may say, my cholesterol is normal. Why do I have to be on it? This is for preventing future complications. And that is why it is important. That's why I'm giving you my example. Although when I had my heart attack, my cholesterol was normal. My blood pressure was perfectly normal, except I had diabetes. I had no other health history, no family history, but I am on a small dose of Lisinopril. I am on a small dose of beta blocker. I am on a small dose of Lipitor to prevent me getting heart failure in future. So my heart attack was five years ago. I'm perfectly healthy. I go for my echocardiogram every year. They are beating good. So this is why I'm telling you this story. It is important to follow with your teeth and follow the advice what they give you. So you can prevent train wreck. That's what I call them. Because if you don't take care of your body, it's going to scream at you. So it's important to follow the prescriptions or follow the advice they give you. You have to follow your A1C level as far as possible. Keep it below seven. Like, as I told you, I bought it down to 5.7. Do it. It is possible, okay? Follow your kidney function and thyroid function because some of these medications, what you take for both conditions could affect other parts of the body. So that is why we have to have yearly blood test and urine test to evaluate your kidney function. Follow up with your foot doctor and your eye doctor because nerves in your foot and eye can get affected. You develop neuropathy or you develop retinopathy. So need to prevent those things by regular follow-up and early treatment. You have to follow with a diabetic educator or a dietician. A dietician could give you good advice on what... They even give you sample, like the recipes. But I met with a dietician, but they gave me samples of American diet, but I am from India. So I decided to develop my own, Indian recipes that I could use to avoid heart failure and to control my diabetes. So that's why it is important because you need to talk to a Indian nutritionist so that they can probably give you some advice on what type of Indian food needs to be avoided. Hispanic person, talk to a Hispanic dietician who may tell you what type of Hispanic food is good for you and what needs to be avoided. And internet is a good source that you can get all of these information. So what you can eat safely for both conditions. The last thing is palliative and hospice care discussion when appropriate. What you want to be done? If your symptoms are getting worse, and if you are not a candidate for any of the advanced therapies, what next you want to do? Discuss with your family, discuss with your providers, how you want to spend the end of your life at home surrounded by your loved ones. So you need to start the discussion with your providers and with your families when appropriate. So the tips and conclusion, this is my last slide. So treatment for heart failure in people with diabetic is same as for a person without diabetic. You must manage primarily, you must be managed primarily by your heart failure team with the consultation of your diabetic doctor. Know your ABCs as I mentioned, your heart failure symptoms and your diabetic symptoms. Metformin is recommended as first line drug if kidney is working normal and avoid Actos or all these drugs. Use Jordans because research is exploring further benefits in heart failure. So, so far I think that is a good one. If your kidney is a little bit affected, you need to decrease the dose of ACE or ARB or other medications and that is why it is important to have regular follow up with your heart failure team so you can be safe and you can protect other organs of your body. So the last tip, be smart about your heart, control the ABCs of your diabetes. I think that is it and now I'm open for questions. Thank you so much for that informative presentation. If any of our participants today have questions, you can submit them now in the questions tab. While we wait for potential questions, I just want to make our listeners today aware of some additional patient resources which you might find useful. So we do have a series of heart failure education modules on our HFSA website and we do have some additional heart failure webinar recordings on a variety of other topics that you can access through the HFSA website as well. The presentation today for today's webinar can be found in the resource area. Also, you will find a survey that has a variety of questions to get a better understanding of the patient's journey with heart failure. So if you're interested in contributing to that survey, you can download it in that area. Just so you all are aware, HFSA will be sending a survey following this webinar to get your feedback on today's presentation. And we would like to gratefully acknowledge and thank AstraZeneca, Cytokinetics, and Novartis for their support of this webinar program. I was very passionate about this topic because I myself have diabetic and I had a heart attack. So when you asked me, I said, oh, I should talk about that. Absolutely, thank you so much for the information. It looks like the first question that we got in was answered during the webinar discussion today. So I would like to thank you all for participating in today's webinar. A recording of this webinar and others again can be found on hfsa.org. We'd like to once again thank you for your participation and we will keep you posted as new webinar opportunities come available, thank you.

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