**EP399: Stiff Old Hearts with Dr. Fiona Foo Part 2**
**Dr. Auric Bishop:** Welcome, my name's Dr. Auric Bishop. I'm a cardiologist, an author, and a keynote speaker. I'm the CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes, someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, and cholesterol for better health. If you enjoy this podcast, I would be honored for a five-star review. You can share it with your family and friends. It may well save someone you love.
**Warwick:** Hi, my name's Warwick, and welcome to my podcast and videocast station. Today, I'm running part two of a podcast on heart failure with preserved ejection fraction. My special guest is Dr. Fiona Foo, an interventional and general cardiologist in the Sydney Cardiology Group. She works out of Macquarie Uni Hospital and works all around Sydney. Importantly, her interests are not just preventing heart disease, but understanding the concepts around women and the impact on women's sports. It's an absolute pleasure to share with her. This is part two, so if you've missed part one, go back and listen to it.
**Warwick:** Hi, Fiona. How are you?
**Dr. Fiona Foo:** Yeah, great.
**Warwick:** Fiona's been on the podcast station before, other than part one. She was good enough to speak with me about climate and cardiovascular disease. Those podcasts were number 248 and 249, and I had such good feedback from those that I'm really pleased that Fiona's found the time to share again today. We're talking about heart failure with preserved ejection fraction. Heart failure, HFP, preserved E, ejection F for fraction, so HEF-PEF. For those who want a little bit of doctor lingo, so we're talking HEF-PEF. It's when the heart doesn't relax properly. Big drivers are age, obesity, and hypertension. It can cause shortness of breath, swelling of ankles, and can be a very difficult thing to tease out.
We talked about the diagnosis in the last podcast and the sort of things that put people at risk, things like age, female sex, obesity, high blood pressure, diabetes, renal failure—all these things are super duper important. But we're going to talk today about how do we treat it once we've identified it. And then when we've drawn a line under therapy, I'd really like to hear what Fiona thinks about how you guys who are out there listening can reduce your future risk of heart failure with preserved ejection fraction.
So without any further ado, Fiona, do you want to just have a chat about how you might view someone who's coming to your office with a bit of shortness of breath and your next steps and then management for that person?
**Dr. Fiona Foo:** Sure. So as we talked about, you know, the diagnosis, the symptoms, and the signs. I mean, when they come to see us, we do an echo, like an ultrasound of the heart, to look to see what the heart function is, whether it is reduced or whether it is preserved. There are some different parameters for that. But actually, in terms of heart failure now, there is this overriding, I guess, recommendation that everyone with heart failure should be treated with something called an SGLT2 inhibitor.
And so regardless of whether it's reduced, like HEF-REF or HEF-PEF, but let's just take a step back before I go into that. Let's talk about someone who comes in, they're short of breath, and they look like they're in heart failure. So the first thing you want to do is get rid of the fluid and reduce their symptoms. So diuretics, so things such as Furosemide, Lasix, are what you're going to be used to reduce or get rid of that fluid. So it makes you pee out fluid, right?
Before we go too much further, for those listening, in part one of this, we had the chance to talk a little bit about why people actually have more fluid on board. So I strongly suggest you go back and listen to that so that you've got some understanding of why, as hearts fail, they actually do accumulate that extra fluid because that's what causes the symptoms. Sorry to interrupt, Fiona, keep going.
**Dr. Fiona Foo:** Yeah, no, no, I think that's important. So the main thing, first of all, is to get rid of all that fluid. Then, you know, people will feel better. But then kind of more chronically or like after that is being on all these new therapies for HEF-PEF, which, you know, to be fair, we didn't actually have them many years ago because there wasn't much data for it. But these SGLT2 inhibitors, so the ones you may have heard of, so empagliflozin or Jardiance, and then dapagliflozin or Farxiga, have been used. So these are pretty much first-line in patients with heart failure, so HEF-PEF as well as HEF-REF.
I might jump in there because SGLT2 is a bit of an acronym. And S stands for sodium, GL stands for glucose, T stands for transport, and number two means it's the second transport system in a part of the kidney, in one of the early parts of the kidney, where fluid, sodium, and glucose can all be exchanged. What these medications do is shut down this particular transporter so that glucose doesn't get reabsorbed into the bloodstream; it goes out in the urine, and so it creates a tiny bit of diuresis, meaning that fluid leaves the body. But importantly, it gets rid of salt and it gets rid of sugar.
**Dr. Fiona Foo:** And that's got a really positive effect, hasn't it?
**Dr. Auric Bishop:** Yeah. Initially, they were found, as you mentioned, they get rid of sugar because they were initially investigated as, well, used as diabetic drugs. But then they were found to be even like, you know, heart drugs; they're better for heart failure. And so these medications, apart from reducing the risk of heart failure, like hospitalizations or admissions, as well as, I'm sure I'm allowed to talk about this, but cardiovascular death. So these medications have beneficial effects for your heart and reduce.
When you get diagnosed with heart failure, it would reduce further heart failure, hospitalizations, and unfortunately that cardiovascular mortality that is associated with heart failure. So you've mentioned diuretics. Diuresing people, what are the drugs that we use there, Fiona? People may have heard of these, or they may have a family member, a parent who might be seeing the doctor and getting these drugs. What are the sort of names of the drugs that we use, and how do we sort of use them? Do they have any risks? Are they pretty safe or not?
**Dr. Fiona Foo:** I think we may have frozen a moment.
**Dr. Auric Bishop:** Yeah, I think we've got a minor technical glitch. Are we back on, Fiona? Can you hear me?
**Dr. Fiona Foo:** Yeah, I can hear you. Can you hear me okay?
**Dr. Auric Bishop:** Yeah, yeah. Mine just said it was unstable, but it could be because I'm on my phone. What was I talking about? Would you like me to ask that question again just to reset?
**Dr. Fiona Foo:** Yeah, I think, well, no, so the main diuretics were furosemide or Lasix, which is one of the most common ones to use. You can have it orally, and depending on the dose, you can increase it; like some people are on a small dose, but they can increase the dose of it to like twice a day, and you can also have it intravenously. So that's in the hospital when you have severe acute heart failure. So that's the most common one that's used.
The other one that we use is a mineralocorticoid receptor antagonist, something called spironolactone or Spactin that sometimes people call it as well. And that's a really good diuretic, and I find it also a good blood pressure medication as well. That's actually indicated in heart failure with reduced ejection fraction. But there is also some evidence in HEF-PEF, but there's another new type of similar agent used in HEF-PEF now. I mean, I can get into that now, but essentially that's something called finerenone, which is a non-steroidal mineralocorticoid receptor antagonist, which has also been shown to reduce heart failure, hospitalizations, and death in patients with HEF-PEF.
I'll jump in there briefly because a mineralocorticoid receptor antagonist is an absolute mouthful. But for those listening, what it really sort of boils down to is that some of the hormonal systems which regulate salt and blood pressure in our bodies work through these particular pathways. And so these are agents that act on hormonal systems, which get thrown out of whack when the heart is under load and under pressure. So these medications are trying to rebalance hormonal pathways.
**Dr. Fiona Foo:** So finerenone, sorry about that.
**Dr. Auric Bishop:** Yeah, no, no. So I think, so I guess, okay. Let's say a patient comes in with heart failure, so HEF-PEF, so acutely we give them the diuretics, so mainly furosemide or Lasix. And then after that, we can even at the same time start them on these SGLT2 inhibitors. And now there is some evidence—it's not in the guidelines though, yet, in the Australian guidelines—but there is evidence for these other mineralocorticoid receptor antagonists, such as this new one called finerenone, particularly for HEF-PEF. But as I said, spironolactone is also another one that has been used in HEF-REF and is also useful as a diuretic as well.
And so once you've started, obviously you've got, from what you describe, an acute response to this patient who's got shortness of breath, fluid retention, and you look to diurese or take that fluid away. And then you've got a longer-term sort of management strategy, which would be the SGLT2 inhibitors and the mineralocorticoid agents, spironolactone or finerenone. Are there any other aspects of therapy ongoing you'd be looking at, such as blood pressure?
**Dr. Fiona Foo:** Yeah, so exactly. So that's the most important thing with HEF-PEF, that apart from these agents, the main management of HEF-PEF is actually managing all their what we call comorbidities or their other risk factors. And as we've mentioned, so high blood pressure—so managing hypertension, diabetes, obesity, chronic kidney disease as well—they're also really important, also interrelated.
**Dr. Auric Bishop:** Should we talk about hypertension?
**Dr. Fiona Foo:** Well, look, we've talked about the management there a bit. We really probably also want to throw in there that if patients can exercise, that will offer them some benefit as well. So when we think about management strategies, often we think in terms of medical therapy interventions but also non-medical therapy interventions. So things like exercise really pay a dividend. But that's probably a reasonable overview of where we can treat heart failure with preserved ejection fraction for now. Why don't we talk about prevention?
**Dr. Auric Bishop:** In that space of prevention, high blood pressure is pretty close to the top of the pops, actually. So yeah, let's talk about it.
**Dr. Fiona Foo:** Exactly. So I think, you know, we're chatting about how unfortunately in Australia and worldwide, we're not getting to blood pressure targets. People forget about blood pressure, or they don’t get it checked. So it's actually a bigger problem than we know. But it's so important. As I said, hypertension is one of the most significant risk factors for HEF-PEF, and it increases particularly with age. So I think, first of all, checking your blood pressure so you know what your blood pressure is and then managing your blood pressure so that you get down to those targets.
And so anyone with high blood pressure, the target's kind of down to less than 130 over 80, you know, for anyone with high blood pressure. But, you know, being lower is generally better. But would you agree?
**Dr. Auric Bishop:** Look, I've become excited about the boring. So I love to see good cholesterol levels. I love it when my patients come back and say nothing's happened. I love it when we get low blood pressure readings. My patients sometimes think I fuss around and fuss around because their GP says, "Oh, it's a bit borderline, we'll just keep an eye on it." In my opinion, that's just unacceptable. If someone's blood pressure is 130 odd systolic and we can get it down to say 115 or 120 and reduce that blood pressure by 10%, then that 10% reduction is impacting 100,000 beats per day. A 10% reduction on a heart that's beating 100,000 beats per day—that is just insanely good sense. You don't even need to know anything about physics or anything else to go, "Oh geez, that makes sense. That's going to reduce the work the pump does."
**Dr. Fiona Foo:** And it has been shown, yeah, that if you reduce it, you do have a significant reduction in heart failure, like your blood pressure. And as we know, it also reduces your risk of plaque in your artery, so atherosclerotic cardiovascular disease.
**Dr. Auric Bishop:** And it makes perfect sense. Look, the only other thing I'd add in there, Fiona, is almost routinely—and I think my patients now understand that I do this almost as a gold standard—some arc up a little bit, but almost as a gold standard, I do 24-hour blood pressure monitors on everyone. Because single measurements and a couple of measurements here and there, and even home measurements, just don't give us that same data set that a 24-hour blood pressure monitor does.
For those who are listening and don't know what a 24-hour blood pressure monitor is, you basically put a cuff on. It's hooked up to a little box that's about the size of a Walkman that's attached to your belt or around a sling. You wear it for 24 hours. It takes a blood pressure measurement every half an hour and every hour overnight, and it graphs it out, averages all the numbers. You get a mean, all that information, so you really, really know what load the heart is under over a 24-hour period. And it gives you extra little bonuses. Like the graph will tell you if the timing of the blood pressure is working well for that person.
I pick up people with obstructive sleep apnea because surprisingly their blood pressure goes up at night. And I go, "Well, that doesn't work. Something else must be going on." And so I turn up obstructive sleep apnea. So I'm super focused on blood pressure. I think lower is better. And I particularly encourage the use of 24-hour blood pressure monitoring.
**Dr. Fiona Foo:** Yeah, I concur with that. I definitely do the same. I think it's much more useful because, yeah, these one-off blood pressure measurements, especially when they're coming to see us. But also even patients doing it at home is useful, but then, you know, it's going to change at different times of the day, what stress they're under, and things like that. So yeah, I agree with that. But yeah, I think it's like, I think blood pressure is becoming that the lower the better. It's like cholesterol as well. You know, that's another topic, but the lower the cholesterol, the better. You know, you don't have any problems. Like there's no problems getting your cholesterol as low as possible.
**Dr. Auric Bishop:** Yeah. Look, basically, I say to my patients, because many patients and people listening here will go, "Well, what's the best blood pressure? What's the best blood pressure?" Because everyone wants to know the number. Well, of course, once you stop and think about it, there isn't a number. There can't be a number. A perfect blood pressure for a 12-year-old girl cannot be a perfect blood pressure for an 85-year-old male. So there is no perfect number. But for every person, there's a blood pressure where if they're below that blood pressure, they will have symptoms of low blood pressure or what we call hypotension and can't function. So we can't run them that low.
But above that point, you don't know where they are really. So often, although it sounds a bit odd, I often try and run my patients so that they might have a hypotensive episode once a week or once a fortnight. So we know they're incredibly close to as low as possible. And by doing that, we're really offloading the heart. I explain it to them. I let them know that, you know, if we've gone too hard, we just back off. But that's, I'm trying to actually go as close as I can to an episode of low blood pressure.
You know, if they've worked in the garden, they're a bit dehydrated on a hot day, they stand up quickly, they're a bit lightheaded, and that occurs once a week, once a month, once, you know, every six months—perfect. And then I guess, yeah, so I guess the theory of that is also that, same with cholesterol, like the longer you keep your blood pressure elevated, that's when you're going to get these changes to the heart and then increase your risk of that problem with HEF-PEF and that problem with the relaxation, so those structural changes.
So, yeah, I think high blood pressure is really important. And it also helps with the therapies that, you know, people worry that it gets too low with some of the therapies, but if you're not symptomatic from it, you know, some people, like females have a lower blood pressure in general, so they're not going to be as symptomatic, you know, at those lower blood pressures as males, for example. Some people can tolerate that lower blood pressure.
**Dr. Auric Bishop:** 100%. I don't treat the blood pressure. I treat or I'm concerned if they have a symptom from low blood pressure. Low as possible is fantastic. And I'm only really worried if they're having symptoms from that.
**Dr. Fiona Foo:** So I'm going to go on to, I think the other big management and kind of prevention, actually prevention and treatment, is that of obesity and being overweight. I think that's really important because this is one of the biggest risk factors for HEF-PEF and it's one of the biggest types of HEF-PEF. So I think in terms of prevention for your listeners, we need to keep that healthy body weight.
All right. And then diet and lifestyle, I think diet and exercise are a big proponent of that and keeping that healthy weight. But in terms of, I guess, prevention, but also treatment, one thing I didn't mention was these new medications for weight loss have actually been shown to be beneficial in patients with HEF-PEF. So once you do have diagnosed with that kind of obesity-related HEF-PEF, being on these obesity medications, the two main types that are available in Australia are Wegovy or semaglutide, and then the other one is Manjaro or tirzepatide.
**Dr. Auric Bishop:** Okay, so Wegovy or semaglutide is a GLP-1 receptor agonist, and then you can say it. Look, people may also have heard of Saxenda, which was the very early one on the market. And people will have probably heard of Ozempic. So Fiona's talking about that group of drugs, GLP-1A agonists, which basically alter the hormonal pathways of the way the body deals with sugar and the gut perceives appetite. And these agents are very powerful at straightening out people's sugars, reducing appetite, and really have been incredibly compelling in that space of weight reduction. So Wegovy, Ozempic, Manjaro are all the words that you may have heard. These modern agents are shots or injections once a week. Saxenda was the early one to the market, but it's probably not being used quite as much.
**Dr. Fiona Foo:** Do you think they actually took it off recently?
**Dr. Auric Bishop:** Yeah, the same company is producing Ozempic and Wegovy.
**Dr. Fiona Foo:** Yeah, okay. So sorry to jump in there, Fiona, but yeah, keep going because this story about weight reduction, not only to prevent but to be part of the strategy for treatment is really important. I might ask, are you aware of any outcome data that would suggest by losing weight you improve the outcome for people who have been diagnosed with HEF-PEF?
**Dr. Fiona Foo:** Yes. So, well, definitely with these, with Wegovy and Manjaro, both of them have been shown that they reduce HEF-PEF heart failure hospitalizations, as well as the combined HEF-PEF hospitalizations and cardiovascular death, just with them alone. And actually, interestingly, it's independent of your weight loss.
And actually, and I think that's because, so these agents, apart from the weight loss, they have all these other beneficial effects. You know, they've got the, like reducing your sugars, but they have all these anti-inflammatory effects on the heart, your brain, all these other things and your guts that all reduce your risk. But so, so essentially apart from the fact that they—you lose weight or you feel better—these agents have been shown to improve your symptoms, improve your heart failure hospitalizations, which is, you know, which is really important. And that kind of combined heart failure hospitalizations and cardiovascular death.
And so that's why I said these are really important in this big obesity, diabetes kind of group of people who have HEF-PEF. So, you know, people can't feel that, you know, they're just using it. So it is important. Apart from just the weight loss, they actually have shown the data to reduce that risk of worsening heart failure.
It's very, very important. And for those who are overweight, then a conversation around the importance of bringing that weight under control is critical. We know that increased weight is linked to what we would generally call cardiometabolic issues. Now that's a bit of a mouthful, but that means that the heart and the body and the way it metabolizes and uses its energy is dysfunctional. It doesn't work properly with too much weight. Extra weight drives inflammation, and we know that the consequence can be impairment of renal function with time, impairment of liver function with time, and here's the really scary one—and this is the one, Fiona, that I speak with my patients about—an increased risk of dementia with obesity driven from these metabolic abnormalities.
One doesn't want to be a pain in the ass and be beating people up for carrying too much weight because otherwise you look like a judgmental, miserable doctor. No one wants to do that. I always want to see the best outcome for my patients and want to engage with them and desperately want to see their best journey. But sometimes that will require a really frank and candid conversation around losing some weight, dropping some weight to move to a healthier goal just to protect not just the heart, but your whole body.
And the really nice thing with that is that with the patients I've had over the years who have been able to embrace lifestyle change with or without the help of pharmacological support like these agents, not only do we get these fantastic medical benefits, we get quality of life benefits, and that's gold.
**Dr. Fiona Foo:** I was going to say that because I'm a huge proponent for diet and exercise as well. When patients come back and they're so happy that they're on less blood pressure medications or their cholesterol has come down so much better and they feel better. I can exercise more now. They feel less short of breath—all those things. There's so many beneficial effects for weight loss.
The other thing in addition in terms of problems with obesity and overweight is these obesity-related cancers. And it's something new that I hadn't really been that much aware of. But, yeah, that's actually quite a big risk as well. So, no, it's incredibly important.
In fact, just a quick one before we leave weight. I had a patient, a relatively younger patient, who came back and said, "Doctor, you gave me my son back."
**Dr. Auric Bishop:** Oh wow, how cool is that?
**Dr. Fiona Foo:** So he's able to start playing with his child again. They connected—just so powerful. He had been way overweight, didn't engage with his son—beautiful outcome.
I think the other group, just getting back to the whole HEF-PEF and women issue, is that I see a lot of post-menopausal women. And it's a huge problem. Like they gain so much weight after menopause, and they can't lose it. And so that's when, you know, we do have this conversation that they're trying to lose it, but they can't. That's when I find these, some of these medical, pharmaceutical medications quite useful from their point of view. They just need that little bit of extra help.
But it is, I mean, I guess we'll be talking about that at a later stage, but it is, you know, it's a whole conversation about that and about these medications because they are lifelong medications as well. So, but that's the other group I find really useful in as well. And, you know, these are the ones that do get HEF-PEF, these post-menopausal women who gain weight.
**Dr. Auric Bishop:** Yeah. So, look, I'm going to wrap it up just in the interest of time. We've touched on prevention, blood pressure, obviously, obesity. Risk factors such as age and sex, we can't do anything about, so we just have to run with those. Diabetes, we won't touch on because it's huge. But let's just recognize that it's really important.
I wouldn't mind wrapping up kidney disease, I guess with some of the other ones, it's pretty similar. So kidney disease, just to mention those same SGLT2 inhibitors do improve your kidney function.
**Dr. Fiona Foo:** Yeah, and SGLT2s, I think, have been shown to improve liver abnormalities and brain abnormalities too. So they actually look like they address many of our concerns of that cardiometabolic syndrome. But if people can maintain a healthy weight, they may not even need them. So let's aim for that.
**Dr. Auric Bishop:** It's been fantastic sharing today, Fiona. This was part two of heart failure with preserved ejection fraction. If you haven't listened to the first one, shame on you. Go back and listen to it. We've covered how do we manage it. We talked about taking fluid away. We talked about those agents that protect the heart in the longer term, which is really important. And then we talked a bit about the prevention strategies and really, really put the spotlight on blood pressure and weight.
I think this has just been comprehensive. I really hope it's valuable for those who are listening. Fiona, I know some of your patients will be given these podcasts to listen to, and I really appreciate your sharing. It's fantastic to have this opportunity to to and fro and share this knowledge for people to help them with their best health journey. Was there anything else you wanted to wrap up with?
**Dr. Fiona Foo:** No, no. Thank you for the opportunity to chat.
**Dr. Auric Bishop:** Yeah, well, no, thank you. And I really appreciate you making the time. It's an absolute pleasure on my side. For those listening, I hope you found this as entertaining, informative, and as enjoyable as I have. I really hope you find these a valuable resource. If you do like them, please like it and share it. And if you've got inquiries or questions, drop us a note at info@drwarwickbishop.online.
For now, I am going to wish you the very best. Until next time, lots of gratitude that you've tuned in. And I do hope you live as well as possible for as long as possible. Take care and bye for now.
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