Transcript
Announcer:
You’re listening to On the Frontlines of ATTR-CM on ReachMD. And now, here’s your host, Dr. Steve Jackson.
Dr. Jackson:
This is On the Frontlines of ATTR-CM on ReachMD. I'm Dr. Steve Jackson, and joining me to discuss how we can manage swelling in patients with ATTR-CM is Dr. Kevin Shah. He's an advanced heart failure and transplant cardiologist at Long Beach Memorial Hospital as well as an Associate Professor of Medicine at the University of California Irvine School of Medicine.
Dr. Shah, thanks for being here today.
Dr. Shah:
Thank you for having me.
Dr. Jackson:
If we start with the basics, Dr. Shah, what exactly drives swelling and fluid buildup in patients with ATTR-CM?
Dr. Shah:
ATTR-CM can cause a restrictive cardiomyopathy. That's when the heart muscle becomes stiff from amyloid protein deposition. So even if the heart pumping function appears preserved, the heart has a hard time relaxing. As a result, we see higher filling pressures and congestion, and then the downstream impact of that. And what patients tend to report is leg swelling, shortness of breath, and abdominal bloating.
Dr. Jackson:
And in this population of patients, what early signs of fluid swelling might clinicians overlook?
Dr. Shah:
One overlooked sign is beyond just ankle swelling—sometimes patients will report subtle changes in their trajectory. So things like shoes or socks fitting a bit tighter, maybe some abdominal fullness, maybe their appetite's reduced, or maybe they're just feeling full earlier in their meals. And then even more sometimes patients will report nighttime symptoms, so sometimes they need more pillows to prop their head up when they're sleeping. Sometimes they may notice a little bit of weight gain. And those can all be subtle clues before obvious edema or leg swelling appears.
Unfortunately, fatigue can be a symptom of congestion, and sometimes patients will downplay that and say, “Well, I'm just getting older.” But a lot of times those are signs that are related to fluid.
Dr. Jackson:
So how do you guide patients to monitor and report swelling before it becomes more severe?
Dr. Shah:
I try to keep things practical with patients. I ask them to weigh themselves every morning and try to use the same scale. I usually tell them to track trends and not focus too much on one number, meaning, as you know, you can have an outlier. For just one outlier of a weight change, I say, “Don't overreact to that.” But if there's a trend of weight gain that's accompanied with shortness of breath, worsened swelling, abdominal bloating, or dizziness, then I say, “This is something you need to let us know about.”
I also try to empower patients. I say, “You know your baseline. You know what's normal for yourself. Let us know when something seems out of ordinary for you, and we'll help you respond.”
Dr. Jackson:
For those just joining us, this is On the Frontlines of ATTR-CM on ReachMD. I'm Dr. Steve Jackson, and I'm speaking with Dr. Kevin Shah about how we can approach swelling in patients with ATTR-CM.
So Dr. Shah, if we turn now to prevention and management, what strategies can help prevent recurrent or worsening fluid retention over time?
Dr. Shah:
Certainly, the goal for most patients is to try to remain euvolemic or keep their fluid balance not too high and not too low. That means keeping track of things like sodium intake, taking their medications, and trying to minimize things like NSAIDs when possible. And then on the laboratory side, we're monitoring things like kidney function, natriuretic peptides, and rhythms, and we’re certainly adjusting the doses of diuretics early rather than waiting for a patient to be severely congested. There are certainly a lot of disease-modifying therapies for ATTR-CM, but symptom control still does require meticulous attention to diuretics and diuretic dosing.
Dr. Jackson:
And when swelling becomes clinically significant, how do you approach diuretic therapy in these patients?
Dr. Shah:
I always look at patients' blood pressure, their kidney function, their weight trend, their symptoms, and, if I'm seeing them in person, their clinical exam. I always ask myself, “What is the loop diuretic dose that works for that patient?” Meaning, as you know, for each patient, there's a threshold of milligrams for loop diuretics that tends to cause diuresis and natriuresis.
And I try to avoid big swings in terms of dosing changes because sometimes these types of patients can go from very congested to dizzy or hypotensive, or they can even have some kidney injury if you move the dose too quickly. Many of these patients start off on furosemide, but oftentimes they're switching to loop diuretics like torsemide or bumetanide, particularly if there's an absorption issue.
And then I'll certainly add other diuretics beyond loop diuretics. These are things like thiazide-like diuretics, but when I do that, it certainly requires close attention to renal function and potassium concentrations. These patients require a lot of attention, particularly as we're trying to find this balance between not too congested and not too dry.
Dr. Jackson:
Finally, Dr. Shah, what practical advice can clinicians offer to patients with ATTR-CM who are experiencing swelling?
Dr. Shah:
I would say, “Certainly don't ignore swelling, but don't panic either. Track your weight, limit high-salt foods, take diuretics as prescribed, and call early if swelling is noticed and it's progressing.” I also remind patients that more diuretic is not always the right answer. Sometimes it's other issues. Sometimes it's a rhythm issue. Sometimes it's a medication issue. Sometimes we need more labs, and so just the swelling alone—I try not to overreact to it. But in the constellation of everything we've described so far that is suggestive of fluid retention, I certainly want them to call our team and let us know.
Dr. Jackson:
That's a great comment for us to think on as we come to the end of today's program, and I want to thank my guest, Dr. Kevin Shah, for joining me to share his perspective on managing swelling in ATTR-CM. Dr. Shah, it was great having you on the program.
Dr. Shah:
Thanks so much for your time.
Announcer:
You’ve been listening to On the Frontlines of ATTR-CM on ReachMD. To access this and other episodes in our series, visit On the Frontlines of ATTR-CM on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
