As the number of obesity-related deaths from heart disease have drastically increased over the past several decades in the United States, health care leaders across the nation have been investigating ways to improve care for patients facing these conditions, which can compound and worsen one another.
It’s this pursuit that led cardiologist Josephine Harrington, MD, to bring a unique concept to the University of Colorado Anschutz Medical Campus — establishing a new clinic dedicated to helping patients experiencing obesity and heart failure by simultaneously treating both conditions.
“The clinic’s purpose is to implement a multi-pronged treatment approach for these patients that emphasizes both intentional weight loss, as well as optimal treatment and care for their heart failure,” says Harrington, an assistant professor of cardiology in the CU Department of Medicine.
The clinic, which opened on campus this fall, specifically treats patients experiencing obesity and a type of heart failure called “heart failure with preserved ejection fraction” (HFpEF), where the heart can squeeze effectively but patients still experience symptoms of heart failure, including swollen legs, trouble breathing, and difficulty with exertion.
Harrington says the clinic will serve “the sickest of the sick” within this population, meaning people experiencing HFpEF and obesity who also have other risk factors. This includes patients with established cardiometabolic disease (which in most cases means that they have type 2 diabetes), patients who have a high number of symptoms, patients who’ve had recurrent heart failure hospitalizations, and any patient who “might stand to benefit the most from an intensive, multi-faceted approach to treat their HFpEF and obesity conditions,” she explains.
For each patient who visits her clinic, Harrington and her nurse manager, Carolyn Blue, BSN, MPHc, craft an individualized treatment plan that may include interventions such as prescribing incretin-based therapies, like semaglutide, tirzepatide, or other glucagon-like peptide-1 (GLP-1) drugs — often referred to as weight loss drugs — that can help improve both conditions.
Josephine Harrington, MD, (left) and Carolyn Blue, BSN, MPHc (right) are caring for patients experiencing obesity and HFpEF.
The need to simultaneously treat obesity and heart failure
When it comes to patients with HFpEF, those who also experience obesity are often the most symptomatic, typically having a lower quality of life and higher risk of hospitalization, Harrington explains.
“These two conditions are so closely interrelated. Obesity leads to a lot of HFpEF cases, and then once patients have both HFpEF and obesity, they experience a significant number of negative symptoms because their two conditions are further working against each other,” she says. “You can think of obesity as a multiplier of HFpEF, because it is both a risk factor and a magnifier of HFpEF.”
Prior to joining the CU Department of Medicine, Harrington was a fellow at Duke University, gaining expertise in heart failure and transplant care as well as obesity care. During her fellowship, she came across heart failure patients who needed a heart transplant but could not get one because of their obesity. Wanting to help this population, she started a clinic that aimed to support these patients’ weight loss efforts and successfully helped several patients lose enough weight so that they could get a heart transplant.
“It was, for me, the first example of how big a difference obesity management can play in heart failure outcomes,” she says. “I decided I wanted obesity management to be a part of my clinical practice, and when I surveyed the spectrum of heart failure, I found that obesity had the biggest negative impact on the HFpEF population.”
Although obesity and HFpEF have become more common conditions over the years, there historically has been a lack of effective treatment options.
“Patients with HFpEF and obesity were faced with this double whammy of not having good treatment options for their HFpEF and not having good options for their obesity,” she says. “That’s starting to change, as both HFpEF and obesity therapies are now emerging and evolving.”
Can weight loss drugs improve heart health?
Among the new therapies that have recently emerged and may be beneficial to patients experiencing HFpEF and obesity are incretin-based therapies like semaglutide, tirzepatide, and other GLP-1 drugs, which are commonly used for the treatment of type 2 diabetes and weight loss. Popular brand names of semaglutide include Ozempic and Wegovy.
“These are really exciting therapies, because they cause meaningful weight loss — between 15% and 20% of your body weight, which is enough to make a really big clinical difference on multiple markers of cardiovascular risk. And, really for the first time ever with these drugs, we’re actually seeing evidence of cardiovascular benefits,” she says.
There have been multiple trials with semaglutide that have demonstrated that this therapy can have significant improvements in cardiovascular outcomes among patients with a high risk of cardiovascular disease. For patients with HFpEF and obesity, research has shown that they lose significant weight and have significant improvement in different markers of heart failure severity, Harrington explains.
“We know that when semaglutide is used for anti-obesity therapy in patients with HFpEF, it meaningfully improves their quality of life,” she says.
Another emerging medication that is similar to semaglutide is tirzepatide. Popular brand names of this medication include Mounjaro and Zepbound. Research on tirzepatide is ongoing, but early data suggests the medication may help reduce heart failure hospitalizations for patients experiencing obesity and HFpEF, she explains.
“However, I think people are still getting comfortable with using these therapies, and so my clinic is an opportunity to do a multi-pronged treatment approach for this population who really needs extra care,” Harrington says.
Building a treatment plan
As a newer and smaller clinic, Harrington is initially focusing on treating patients who have HFpEF and obesity as well as other risk factors like cardiometabolic disease and a history of hospitalizations.
“If it appears that obesity is one of the major drivers of a patient's heart failure and they believe weight loss would be a key treatment option to improve their health, then they will make a great fit for my clinic,” she says, noting that most of her patients are referred to her by other cardiologists and health professionals.
When a patient first visits the clinic, Harrington has two goals: understand their HFpEF and their experience with their weight.
“I need to make sure we’re treating their HFpEF with the appropriate medications and ensure that there is nothing else contributing to or driving their HFpEF,” she says. “Then, there’s the weight management piece, which is the most time consuming because I have to understand their weight history, what they have tried in the past, and what challenges they may be facing.”
Harrington will discuss different anti-obesity medications, like semaglutide, and whether any of those medications may be appropriate for the patient. There may be cases where these medications are not a good fit and other approaches, like bariatric surgery (a weight loss surgery), would be a better option. Other therapy interventions Harrington may use include behavioral counseling or referring patients to nutrition and psychiatry experts.
“I think people tend to think of obesity as something that you fix, but we’re increasingly understanding that obesity is a chronic condition, just the same way that HFpEF is, and so they both require ongoing chronic treatment,” she says.
A key element Harrington pays attention to is how the different treatments interact, given the close interrelation between obesity and HFpEF.
“The advantage of being a dedicated clinic to these conditions is that we have the opportunity to optimize care and individualize treatment plans for each patient,” she says. “Appreciating the nuances of how these conditions interact will be part of my practice, especially as I do simultaneous parallel research.”
Combining clinical care and research to help patients
When Harrington pitched the idea of this clinic — which is one of only a few in the country that are dedicated to addressing both these conditions — her aim was not only to offer clinical care but also to advance research on these conditions.
“My clinical and research interests are so closely aligned that they'll be able to really empower and inform each other, which will hopefully improve care for my patients in the long run,” she says. “I hope to show that treating both conditions is the best option for these patients to really make the biggest difference in their quality of life.”
Harrington plans to study and learn from the patients in her clinic, documenting their characteristics and how they respond to different treatments, with hopes of better understanding how obesity and HFpEF interact and how to most effectively treat both conditions. This will not only improve how she conducts care in her clinic, but it will also allow her to share her findings with other health professionals across the country.
“This is important because the treatment options are changing really quickly, and there are going to be optimal medical therapies for these patients — but we haven't really identified what the magic combinations are yet,” she says. “I’m really hoping that we can use this clinic to make sure that patients are getting the best standard of care for both HFpEF and for obesity, and I think the most effective strategy will be treating both of their conditions together because of how closely interrelated they are.
“More broadly, I hope that this clinic is going to be a venue where we can learn more about patients with HFpEF and obesity and use it as a place to continuously improve care for this population.”
