1 00:00:00,119 --> 00:00:02,261 This podcast is sponsored by Z Life fest. 2 00:00:02,657 --> 00:00:05,355 Xo has continuously improved Life fest for over 3 00:00:05,355 --> 00:00:07,735 20 years, leading to a median real world 4 00:00:07,735 --> 00:00:09,417 wear time of 23.4 5 00:00:09,417 --> 00:00:12,060 hours per day, and an Ai enhanced algorithm 6 00:00:12,116 --> 00:00:14,895 that delivers 0 median false alarms at 90 7 00:00:14,895 --> 00:00:17,217 days. The newest life fest Garment is lightweight, 8 00:00:17,457 --> 00:00:20,011 breathable and preferred by patience for its comfort. 9 00:00:20,251 --> 00:00:21,469 Learn more at life 10 00:00:21,847 --> 00:00:22,645 innovation dot com. 11 00:00:25,934 --> 00:00:27,074 Worldwide, cardiovascular 12 00:00:27,454 --> 00:00:30,254 disease affects the lives of hundreds of millions, 13 00:00:30,814 --> 00:00:34,262 Dedicated cardio nerds everywhere. Are working hard to 14 00:00:34,262 --> 00:00:37,841 fight this global epidemic. These are their stories. 15 00:00:39,432 --> 00:00:42,310 Hi, everyone. Dan M here. On behalf of 16 00:00:42,310 --> 00:00:44,139 all of us at coordinators, we are thrilled 17 00:00:44,139 --> 00:00:46,206 to bring you our decipher for the guideline 18 00:00:46,206 --> 00:00:49,960 syringe for the 20 20 2AHA 19 00:00:49,960 --> 00:00:52,359 guideline for the management of heart failure, get 20 00:00:52,359 --> 00:00:55,000 ready for short and bite sized, high impact 21 00:00:55,000 --> 00:00:57,479 critical did yet based questions designed to highlight 22 00:00:57,479 --> 00:00:59,974 core concepts based on cutting edge evidence that 23 00:00:59,974 --> 00:01:02,531 are relevant to your practice. The cases we 24 00:01:02,531 --> 00:01:05,329 use are hypothetical and for educational purposes only. 25 00:01:05,648 --> 00:01:07,886 This series was developed by car and created 26 00:01:07,886 --> 00:01:09,379 in collaboration with the American 27 00:01:09,817 --> 00:01:12,122 association and the Heart failure Society of America. 28 00:01:12,360 --> 00:01:14,824 It was created by 30 trainees spanning college 29 00:01:14,824 --> 00:01:17,783 students through advanced fellowship with mentorship doctor Anu 30 00:01:17,783 --> 00:01:20,420 la, Doctor. Robert Men and Doctor. Nancy Sc, 31 00:01:20,659 --> 00:01:23,456 we thank Doctor. Judy And doctor Elliot Amin 32 00:01:23,456 --> 00:01:25,548 for their guidance. So join us as we 33 00:01:25,548 --> 00:01:28,026 get to learn about the guidelines and beyond 34 00:01:28,026 --> 00:01:31,142 from 16 leading faculty experts. With that said, 35 00:01:31,382 --> 00:01:32,581 it's time to get nerdy. 36 00:01:35,150 --> 00:01:37,942 The following question refers to section 5.1 of 37 00:01:37,942 --> 00:01:39,297 the 2022 38 00:01:39,297 --> 00:01:39,797 a 39 00:01:40,254 --> 00:01:43,046 acc, H guidelines for the management of heart 40 00:01:43,046 --> 00:01:43,285 failure. 41 00:01:43,937 --> 00:01:45,528 The question is asked by ke School of 42 00:01:45,607 --> 00:01:48,232 Medicine and Usc Medical student and cardio earth's 43 00:01:48,232 --> 00:01:49,346 intern, First El, 44 00:01:49,982 --> 00:01:52,227 answered first by recent advanced heart failure and 45 00:01:52,227 --> 00:01:54,777 transplant fellowship graduate and our faculty at the 46 00:01:54,857 --> 00:01:57,247 University of Chicago and c chair for the 47 00:01:57,327 --> 00:02:00,452 Cardio critical care cardiology series, Doctor Mark Be, 48 00:02:00,771 --> 00:02:03,403 and then by expert faculty, Doctor Vi Bo. 49 00:02:04,200 --> 00:02:06,434 Doctor. Ba is the Marion Gordon Keen sc, 50 00:02:06,753 --> 00:02:07,471 professor of Medicine, 51 00:02:08,124 --> 00:02:10,122 director of the Winter center for heart failure 52 00:02:10,122 --> 00:02:12,599 research and an advanced heart failure and transplant 53 00:02:12,599 --> 00:02:13,099 cardiologist 54 00:02:13,558 --> 00:02:15,635 at Baylor College of Medicine in Houston, Texas. 55 00:02:16,368 --> 00:02:18,144 She the former president of H, 56 00:02:18,680 --> 00:02:21,788 former senior associate editor for circulation, and the 57 00:02:21,788 --> 00:02:23,700 current editor and chief of Jack Heart failure. 58 00:02:24,272 --> 00:02:26,180 Doctor Bo was the Vice chair of the 59 00:02:26,180 --> 00:02:28,723 writing committee for the 2002 heart failure guidelines. 60 00:02:29,200 --> 00:02:30,948 Doctor Bo is an honor to have you 61 00:02:30,948 --> 00:02:33,193 with us. A great pleasure for me to 62 00:02:33,193 --> 00:02:35,184 be with you at the cardio nerds. It's 63 00:02:35,184 --> 00:02:38,632 a fantastic platform for timely and insightful 64 00:02:39,168 --> 00:02:40,841 conversations in cardiology and heart failure. 65 00:02:41,414 --> 00:02:42,531 Thank you for inviting me. 66 00:02:43,647 --> 00:02:45,083 Jason, thank you so much for the intro. 67 00:02:45,322 --> 00:02:47,236 And Mark, my question for you today is 68 00:02:47,236 --> 00:02:49,390 about a 63 year old patient with the 69 00:02:49,390 --> 00:02:52,194 past medical history of hypertension. And type 2 70 00:02:52,194 --> 00:02:52,694 diabetes 71 00:02:53,150 --> 00:02:54,582 who presents for routine follow up. 72 00:02:55,378 --> 00:02:57,528 Your reports feeling in general Good health and 73 00:02:57,528 --> 00:02:59,142 enjoys 2 mile walks daily 74 00:02:59,852 --> 00:03:01,767 Review of symptoms is negative for any symptoms. 75 00:03:02,165 --> 00:03:04,399 Which of the following laboratory studies may be 76 00:03:04,399 --> 00:03:05,117 beneficial for screening. 77 00:03:06,473 --> 00:03:08,865 Option a is Nt prob b p, 78 00:03:10,153 --> 00:03:11,980 option b, ck k mb. 79 00:03:13,093 --> 00:03:14,603 Option c, troponin, 80 00:03:15,715 --> 00:03:16,271 option d, 81 00:03:17,003 --> 00:03:17,503 Crp 82 00:03:18,757 --> 00:03:21,547 and option e, none of the above. And, 83 00:03:21,706 --> 00:03:23,301 Mark, oh, yeah, I love your help figuring 84 00:03:23,301 --> 00:03:24,497 out what the next step should be for 85 00:03:24,497 --> 00:03:26,830 this patient. Thanks Harsh. That's a great question 86 00:03:26,830 --> 00:03:28,189 and comes up frequently clinic. 87 00:03:28,990 --> 00:03:32,110 Correct answers is a, nt prob p. The 88 00:03:32,110 --> 00:03:34,030 patient's at risk for heart failure or stage 89 00:03:34,030 --> 00:03:36,380 a, given the presence of risk factors of 90 00:03:36,438 --> 00:03:38,831 hypertension and type 2 diabetes, but absence of 91 00:03:38,831 --> 00:03:40,107 signs of symptoms of heart failure. 92 00:03:41,064 --> 00:03:42,420 Patients at risk for heart failure screened with 93 00:03:42,580 --> 00:03:44,117 B p or anti nt prob 94 00:03:44,509 --> 00:03:46,523 followed by collaborative care, diagnostic 95 00:03:46,899 --> 00:03:49,289 evaluation and treatment in those elevated levels can 96 00:03:49,289 --> 00:03:52,418 reduce combined rates of L systolic dysfunction, diastolic 97 00:03:52,635 --> 00:03:53,432 dysfunction and heart failure. 98 00:03:54,560 --> 00:03:56,227 The stop H trial, which was the saint 99 00:03:56,227 --> 00:03:58,608 vincent screening to prevent heart failure study, is 100 00:03:58,608 --> 00:04:00,672 a large single center trial of patients at 101 00:04:00,672 --> 00:04:03,000 risk for heart failure. That showed B based 102 00:04:03,000 --> 00:04:05,180 screening reduce the composite endpoint of incident 103 00:04:05,480 --> 00:04:08,360 asymptomatic L dysfunction with or without newly diagnosed 104 00:04:08,360 --> 00:04:08,840 heart failure. 105 00:04:09,891 --> 00:04:11,801 Therefore, for patients at risk of developing heart 106 00:04:11,801 --> 00:04:12,039 failure, 107 00:04:12,915 --> 00:04:15,461 peptide biomarker a based screening followed by team 108 00:04:15,461 --> 00:04:18,540 based care, including a cardiovascular specialist optimizing guidelines 109 00:04:18,738 --> 00:04:20,966 directed medical therapy can be useful to prevent 110 00:04:20,966 --> 00:04:23,511 the development of l dysfunction, whether assist systolic 111 00:04:23,511 --> 00:04:26,073 diastolic or and heart failure. Find Is that 112 00:04:26,073 --> 00:04:28,145 class 2a a recommendation with the level evidence 113 00:04:28,145 --> 00:04:30,218 b from a randomized control trial. There is 114 00:04:30,218 --> 00:04:32,689 no indication for measuring troponin, Ck b or 115 00:04:32,849 --> 00:04:34,938 Cr at this time. The main takeaway here 116 00:04:34,938 --> 00:04:36,534 is in patients at risk for heart failure, 117 00:04:37,093 --> 00:04:40,068 screening for pre heart failure using peptide testing 118 00:04:40,127 --> 00:04:41,723 followed by team based care may be helpful 119 00:04:41,723 --> 00:04:43,080 for preventing disease progression. 120 00:04:43,971 --> 00:04:46,516 So about Actually in in my short time 121 00:04:46,516 --> 00:04:47,947 now is faculty have seen us a few 122 00:04:47,947 --> 00:04:49,537 times in clinic. The guidelines are pretty clear 123 00:04:49,537 --> 00:04:51,859 in 1 to screen of peptides, but how 124 00:04:51,859 --> 00:04:54,173 often do you repeat the testing after your 125 00:04:54,173 --> 00:04:54,572 initial screen? 126 00:04:55,211 --> 00:04:58,642 It's a great question. And the examine what 127 00:04:58,642 --> 00:05:00,808 was done in this stop H f trial, 128 00:05:01,047 --> 00:05:03,615 which, this recommendation was formulated 129 00:05:04,149 --> 00:05:06,456 from, they screen on an annual basis. 130 00:05:06,948 --> 00:05:10,145 The approach was very well structured, and a 131 00:05:10,200 --> 00:05:13,849 randomized to the B screening versus own screening. 132 00:05:14,087 --> 00:05:14,904 And if 133 00:05:15,294 --> 00:05:17,292 Amongst the screen ones on an annual basis, 134 00:05:17,452 --> 00:05:19,530 B levels exceeded that of 50. 135 00:05:20,648 --> 00:05:23,066 Per liter is actually a relatively 136 00:05:23,445 --> 00:05:24,085 low value. 137 00:05:24,658 --> 00:05:27,365 If the level exceeded that of 50, they 138 00:05:27,365 --> 00:05:30,630 down refer to this multi disciplinary chair coordination 139 00:05:30,630 --> 00:05:33,988 that included a cardiovascular specialist, As to 1 140 00:05:33,988 --> 00:05:36,614 wonders what did they exactly do because these 141 00:05:36,614 --> 00:05:39,399 individuals were with hypertension diabetes, coronary artery disease, 142 00:05:39,558 --> 00:05:40,536 but without 143 00:05:40,911 --> 00:05:43,229 established heart failure. So what they did was, 144 00:05:43,467 --> 00:05:44,363 they actually 145 00:05:45,052 --> 00:05:45,552 image 146 00:05:46,162 --> 00:05:49,253 and treated the risk factors very effectively. 147 00:05:49,904 --> 00:05:51,283 And when they 148 00:05:51,982 --> 00:05:54,959 enhanced this risk treatment strategies, 149 00:05:55,498 --> 00:05:58,695 the endpoint was very striking in the sense 150 00:05:58,695 --> 00:06:01,589 that both the future development of heart failure, 151 00:06:02,310 --> 00:06:06,790 mace events, and future development of diastolic or 152 00:06:06,790 --> 00:06:07,165 systolic 153 00:06:07,845 --> 00:06:11,944 dysfunction was prevented. So a very important trial 154 00:06:12,404 --> 00:06:15,259 and that gives a glimpse into what this 155 00:06:15,458 --> 00:06:17,524 structure of the screening could be. So back 156 00:06:17,524 --> 00:06:19,932 to your question, top H trial 157 00:06:20,306 --> 00:06:21,736 screened on an annual basis. 158 00:06:22,293 --> 00:06:24,143 Perhaps 1 approach could be 159 00:06:24,533 --> 00:06:25,488 the risk. 160 00:06:25,965 --> 00:06:28,670 If the risk is high, annual screening makes 161 00:06:28,670 --> 00:06:31,454 sense. If the risk is low, like that 162 00:06:31,454 --> 00:06:34,494 23 year old, 1 and probably reduce the 163 00:06:34,494 --> 00:06:39,037 frequency of screening to several years apart. And 164 00:06:39,037 --> 00:06:41,524 maybe only do it when there is a 165 00:06:41,524 --> 00:06:44,640 change either in the profile and or in 166 00:06:44,640 --> 00:06:48,155 the risk category. So the population based screening 167 00:06:48,155 --> 00:06:48,655 levels 168 00:06:49,449 --> 00:06:52,165 rely on cost effectiveness and the pre test 169 00:06:52,165 --> 00:06:52,665 likelihood. 170 00:06:53,203 --> 00:06:56,912 And the stop H trial actually was further 171 00:06:57,048 --> 00:06:59,751 analyzed and the B based screening was found 172 00:06:59,751 --> 00:07:02,557 to be cost effective, and thus it is 173 00:07:02,614 --> 00:07:05,173 likely gonna be in rated in our practice, 174 00:07:05,730 --> 00:07:08,276 especially for the patient, like, the 1 that 175 00:07:08,276 --> 00:07:11,393 you just presented, who truly would benefit from 176 00:07:11,393 --> 00:07:14,576 a screening and optimization of treatment strategies that 177 00:07:14,576 --> 00:07:17,202 are targeted towards heart failure. And it should 178 00:07:17,202 --> 00:07:19,287 be kept in mind that in the Stop 179 00:07:19,367 --> 00:07:20,245 H trial, 180 00:07:20,803 --> 00:07:22,499 there was a multi 181 00:07:22,877 --> 00:07:24,733 disciplinary team. In the 182 00:07:25,110 --> 00:07:26,727 recommendations that we formulated, 183 00:07:27,423 --> 00:07:30,869 we recommend or patients at risk or development 184 00:07:30,869 --> 00:07:31,747 of heart failure, 185 00:07:32,305 --> 00:07:33,523 nat peptide 186 00:07:33,901 --> 00:07:36,476 by a marker based screening followed by 187 00:07:36,790 --> 00:07:38,970 team based care, including a cardiovascular 188 00:07:39,430 --> 00:07:39,830 specialist, 189 00:07:40,710 --> 00:07:43,509 optimizing the guideline directed therapy can be useful 190 00:07:43,509 --> 00:07:44,365 to prevent 191 00:07:44,724 --> 00:07:46,559 feature the development of L dysfunction, 192 00:07:48,236 --> 00:07:49,912 as well as new ones onset heart failure. 193 00:07:50,470 --> 00:07:53,698 The only challenge right now is The 194 00:07:54,072 --> 00:07:57,090 recognition for screening is there among specialists. 195 00:07:57,805 --> 00:08:00,982 It's not widely known by primary care providers, 196 00:08:01,474 --> 00:08:05,010 and it's not widely adopted by the healthcare 197 00:08:05,309 --> 00:08:05,809 systems 198 00:08:06,428 --> 00:08:08,745 and not covered by the payers. 199 00:08:09,399 --> 00:08:11,814 So the importance of this 200 00:08:12,431 --> 00:08:13,729 recognition is critical 201 00:08:14,187 --> 00:08:16,921 or our patients to be provided timely care 202 00:08:17,554 --> 00:08:20,688 This is very similar to screening for cancer 203 00:08:20,986 --> 00:08:23,562 because we now in heart failure as we 204 00:08:23,701 --> 00:08:26,436 discussed earlier that there are specific 205 00:08:26,829 --> 00:08:30,289 treatment strategies that prevents heart failure. And in 206 00:08:30,349 --> 00:08:32,269 individuals who are at higher risk for heart 207 00:08:32,269 --> 00:08:32,669 failure, 208 00:08:33,629 --> 00:08:37,502 treatment with These specific agents such as a 209 00:08:37,641 --> 00:08:40,219 2 inhibitors amongst patients with diabetes 210 00:08:40,758 --> 00:08:43,395 can prevent forte by about 30 percent. 211 00:08:43,967 --> 00:08:45,737 Thus screening is critical 212 00:08:46,349 --> 00:08:49,208 to prevent future risk for development of heart 213 00:08:49,208 --> 00:08:51,828 failure. And I think that's gonna be an 214 00:08:51,828 --> 00:08:52,646 important concept 215 00:08:53,274 --> 00:08:56,335 as we of as healthcare care clinicians 216 00:08:56,875 --> 00:08:59,514 advocate for our patients, for appropriate coverage and 217 00:08:59,514 --> 00:09:02,084 timely care. A fantastic Doctor. Ba I think 218 00:09:02,084 --> 00:09:04,475 that's a key point about the recommendations and 219 00:09:04,475 --> 00:09:06,729 updated guidelines being there and then that translating 220 00:09:07,505 --> 00:09:08,005 into 221 00:09:08,382 --> 00:09:11,024 education for clinicians specifically outside of advanced heart 222 00:09:11,024 --> 00:09:12,933 failure and cardiology and then and the payers. 223 00:09:13,251 --> 00:09:15,081 A follow question I had in terms of 224 00:09:15,081 --> 00:09:15,978 screening, for 225 00:09:16,289 --> 00:09:17,964 yearly screening and let's say a high risk 226 00:09:17,964 --> 00:09:20,037 patient, who many of our patients happen to 227 00:09:20,037 --> 00:09:22,350 have hypertension diabetes that may also be obese. 228 00:09:22,749 --> 00:09:24,663 And we know that Bm tends to be 229 00:09:24,663 --> 00:09:27,313 falsely low in patients with obesity? How would 230 00:09:27,313 --> 00:09:30,030 you interpret B p screening in this type 231 00:09:30,030 --> 00:09:32,907 of situation? 2 answers. In the selling of 232 00:09:32,907 --> 00:09:36,034 mobile obesity, we do know that the peptide 233 00:09:36,034 --> 00:09:39,560 levels will be low. And there are other 234 00:09:40,015 --> 00:09:43,335 modalities by which 1 can examine the heart 235 00:09:43,454 --> 00:09:45,304 and the filling pressures, including 236 00:09:45,677 --> 00:09:46,257 echo c 237 00:09:46,948 --> 00:09:50,204 and other imaging. In the context of a 238 00:09:50,204 --> 00:09:53,580 morbid obese individuals who may even have symptoms 239 00:09:54,600 --> 00:09:57,480 because most of our patients actually do have 240 00:09:57,480 --> 00:10:00,200 symptoms of d, it would be prudent to 241 00:10:00,200 --> 00:10:02,049 of contain imaging in those patients to look 242 00:10:02,049 --> 00:10:04,602 at the left atrial size, the mitral inflow, 243 00:10:04,761 --> 00:10:06,915 at the wall thickness, the structure of the 244 00:10:06,915 --> 00:10:09,706 heart in terms of overall ejection fraction as 245 00:10:09,706 --> 00:10:12,752 well as variables that may suggest diastolic is 246 00:10:12,752 --> 00:10:15,543 dysfunction or even elevated filling pressure. So the 247 00:10:15,543 --> 00:10:16,660 concept of screening, 248 00:10:17,218 --> 00:10:19,872 I believe is gonna evolve as the field 249 00:10:20,264 --> 00:10:21,482 has more evidence 250 00:10:21,940 --> 00:10:24,973 supporting these strategies. There are currently large scale 251 00:10:24,973 --> 00:10:25,473 echo 252 00:10:26,010 --> 00:10:28,245 data, demonstrating very similar, 253 00:10:28,739 --> 00:10:31,770 role for echo screening. As you... We are 254 00:10:31,770 --> 00:10:34,503 all aware, we have now, a very practical 255 00:10:35,040 --> 00:10:38,172 focus point of care ultrasound as well as 256 00:10:38,724 --> 00:10:39,224 other 257 00:10:39,760 --> 00:10:43,269 imaging modalities that are being widely available. 258 00:10:43,668 --> 00:10:45,741 And I think this paradigm is gonna evolve 259 00:10:45,741 --> 00:10:48,629 with even digital technologies that may look at 260 00:10:48,629 --> 00:10:51,370 the cardiac structure in a non amazing manner 261 00:10:51,750 --> 00:10:55,049 and the ability to detect cardiac structural. 262 00:10:56,244 --> 00:10:58,881 May not need to solely rely on biomarkers 263 00:10:58,881 --> 00:11:02,477 markers in essence, nat peptides are an indirect 264 00:11:02,477 --> 00:11:03,616 way of demonstrating 265 00:11:04,649 --> 00:11:07,209 increased filling pressures or myocardial stretch. 266 00:11:07,929 --> 00:11:10,829 Maybe if we were to have affordable, widely 267 00:11:10,970 --> 00:11:11,449 available, 268 00:11:11,784 --> 00:11:12,284 practical 269 00:11:13,065 --> 00:11:16,584 imaging, they could complement biomarker a screening or 270 00:11:16,584 --> 00:11:18,985 in the setting of obesity as you alluded 271 00:11:18,985 --> 00:11:20,365 to add specificity. 272 00:11:20,839 --> 00:11:21,579 And sensitivity. 273 00:11:22,036 --> 00:11:25,069 It's very helpful clarification, and look forward to 274 00:11:25,069 --> 00:11:28,102 further screening patients and being able to combat 275 00:11:28,102 --> 00:11:28,660 heart failure. 276 00:11:29,394 --> 00:11:30,270 With the new guidelines. 277 00:11:31,386 --> 00:11:33,698 Thank you. These were excellent cases, and thanks 278 00:11:33,698 --> 00:11:36,807 for the discussion, and the opportunity to provide 279 00:11:36,807 --> 00:11:39,718 the perspective we'll how the recommendations were formulated 280 00:11:39,777 --> 00:11:42,014 in the guidelines with evidence from the clinical 281 00:11:42,014 --> 00:11:44,092 trials. Thank you so much, Doctor. Ba and 282 00:11:44,092 --> 00:11:45,850 marked for that really wonderful discussion. 283 00:11:46,494 --> 00:11:47,912 Thank you. It was a true pleasure.