Clinical Innovators | Interview by Katlyn Nemani, MD

Alex Reyentovich, MD, is the Director of Heart Failure at Bellevue Hospital Center and Clinical Director of Heart Failure and the Medical Director of the Ventricular Assist Device Program at NYU Langone Medical Center, New York, NY. He is nationally recognized for his expertise in the treatment of heart failure. Dr. Reyentovich completed his residency in internal medicine, chief residency, and fellowship in cardiology at Columbia University Medical Center, New York City. He was born in the former Soviet Union and raised in Brooklyn.

How did you become interested in treating patients with heart failure?
Since medical school, I have been interested in the management of patients with end-organ failure both chronically and in the acute setting. I have always been a bit of history buff, and the history of heart failure peaked my interest early on. Descriptions of heart failure (or dropsy) extend back to works attributed to Hippocrates as well as ancient Egyptian texts. Modern medical and surgical therapies of heart failure have been one of the great medical successes post World War II, and it seemed an exciting time to be part of it. I was correct!

One year ago, you were the cardiologist for the first patient on the East Coast to be implanted with CardioMEMS. How does this heart failure device work, and what has your success been with it in the past year?
CardioMEMS and the CHAMPION trial represent the first success of intracardiac monitoring for management of chronic heart failure. A small device is inserted via right heart catheterization and, on a daily basis, patients transmit their pulmonary artery pressures to a heart failure team. We then look to make adjustments of their medications before there is clinical deterioration. This management strategy has been demonstrated to have a marked reduction in heart failure hospitalizations. We have had some successes and some challenges. Dealing with the extra “data” has been a challenge, but we have adapted.

You recently co-authored a manuscript with Judith Hochman, MD, FACC, entitled “MY APPROACH to the Management of Cardiogenic Shock,” published recently in Trends in Cardiovascular Medicine. What is unique about your management approach?
My focus is on the “critical hour” of cardiogenic shock—the need to act quickly and not allow any prolonged end organ hypoperfusion, which inevitably leads to the spiral of terminal end organ dysfunction and death. I find people are content too often with “opening up the blockade,” but pay little heed to the ongoing end-organ hypoperfusion.

What have we learned in the past few years about invasive versus conservative management of cardiogenic shock?
Cardiogenic shock remains a highly morbid condition with ~ 50% of patients dying during hospitalization. The landmark SHOCK trial let by Judy Hochman and published in the New England Journal of Medicine in 1999 taught us that rapid and early correction of ongoing myocardial ischemia/infarction via percutaneous or surgical revascularization (“invasive management”) is a life-saving treatment modality in patients with cardiogenic shock complicating myocardial infarction. To date, this is the only randomized trial in patients with cardiogenic shock to demonstrate a mortality benefit.

What are the challenges of treating heart failure patients?
The main challenge is that you can control only what you control. What patients do at home with regards to medication and dietary compliance is often outside of our control, but makes a large contribution to patient outcomes and treatment success. In addition there is overall poor recognition by patients and physicians when patients are getting particularly sick and should be referred for advanced cardiac therapeutics (LVAD, transplant). There is an ongoing need for community and physician education.

How do you expect the treatment of heart failure to evolve in the coming decade?
We have several new pharmacologics that have become available. In the next decade, we need to figure out how to best make sure that patients have access to these and other already established life-sustaining therapeutics. Registries have demonstrated that in general there is underutilization of the therapeutics that we already have. In addition, there is no evidence-based therapy for half of our patients with heart failure (heart failure with a normal ejection fraction). There remains a lot of work to be done in these patients. Meanwhile, the field of left ventricular assist devices (LVAD) continues to progress at a rapid clip. The next decade will bring better, smaller, and more widely applicable devices. Stay tuned. Despite the naysayers, these are exciting times and the best is yet to come.

References

1. Hochman, Judith S. et al. Trends in Cardiovasc Med. 2015;25:6:561-2.
2. Hochman J, Sleeper L, Webb J, et al. N Engl J Med. 1999; 341:625-634.

Keywords: CardioSource WorldNews Interventions, Heart Failure, Heart-Assist Devices, Internal Medicine

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