Examining Heart Failure: How to Recognize and Treat the Weak Heart

Aug 26, 2023

Examining Heart Failure: How to Recognize and Treat the Weak Heart

Dr. Munir Janmohamed discuss what is heart failure including signs and symptoms; different types of heart failure; when to go to the doctor; and various diagnostic tests. Dr. Van Selby follows with a discussion on heart failure including how to treat and stay out of the hospital as well as diet, exercise, pharmacologic management, and EP device management. Dr. Liviu Klein will discuss late stage heart failure and the options. Recorded on 06/17/2015. [9/2015] [Show ID: 29724]

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Content

1.25 -> This program is presented by

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74.29 -> Good evening everyone and welcome to

76.88 -> the UCSF Mini Medical School.

79.565 -> Tonight's topic we're going to be

81.08 -> talking about heart failure,

82.49 -> and how to recognize and treat the weak heart.

85.43 -> My name is Dr. Janmohamed and

86.93 -> I'm one of the cardiologists here,

88.97 -> and I specialize in heart failure.

90.955 -> This is an overview of the talks.

93.41 -> We have three talks tonight

95 -> and hopefully by the end you're

96.05 -> really able to comprehensively

97.49 -> understand what is heart failure.

99.08 -> I'm going to start with what is heart failure?

101.27 -> Talking about some of the risk factors

104.48 -> and some of the causes of heart failure.

106.235 -> Then I'm going to talk about some of the diagnostic,

108.215 -> how do the patients present?

109.745 -> What are the symptoms they have?

111.05 -> Then talk about some of

112.22 -> the diagnostic tests to diagnose heart failure.

116.15 -> Then the second talk by Dr. Silva,

117.95 -> my colleague will talk about

119.42 -> mostly the treatment of heart failure.

121.43 -> Then my other colleague, Dr. Klein,

123.53 -> will talk about the end-stage heart failure or

125.66 -> late heart failure and other

126.74 -> therapies for that population.

129.265 -> The objectives over the next 20 minutes,

132.98 -> hopefully you'd be able to identify

134.27 -> what is heart failure.

136.1 -> We'll go over the different types of heart failure.

139.73 -> How common is heart failure?

142.22 -> What are the signs and symptoms?

143.87 -> When should you go see a doctor,

145.895 -> and then some of the diagnostic testing.

148.93 -> I think before we talk about heart failure,

151.31 -> we need to understand

152.42 -> the normal heart and some of the functions of

155.03 -> the heart really to understand some of

156.92 -> the pathologic process that can occur in heart failure.

159.92 -> You can see here the hardest,

161.885 -> you have basically four chambers in the heart.

164.105 -> You have the top chambers here,

165.44 -> these are the failing chambers,

167.06 -> and then you have the bottom chambers.

169.4 -> These are like the workhorse of the heart.

171.77 -> These are contracting the chambers,

173.765 -> and it's divided into the right side and the left side.

176.7 -> You can see on the right side, it's blue.

180.17 -> That means that the blood on

181.82 -> the right side doesn't have any oxygen.

184.615 -> These chambers are separated by

187.175 -> valves or doors and they open and close.

190.76 -> Basically blood will come on

193.31 -> the right side and it

195.35 -> will go to the right ventricle which is

197.39 -> the pumping chamber on the right side and get ejected

200.33 -> out into what's called the pulmonary

201.86 -> valve to the pulmonary arteries.

203.945 -> It go to the lungs and through

205.88 -> the lungs they'll get oxygen,

207.835 -> and then now the oxygenated blood is going to come back

210.59 -> to the left side and now it's red.

213.59 -> Then it's going to go to the

215.045 -> pumping chamber on the left side,

216.5 -> which is called the left ventricle,

218.575 -> and from there it's going to get ejected

220.49 -> out into what's called the aorta,

221.795 -> which is the main blood vessel

223.16 -> that ejects out of the heart.

225.155 -> Then from there it's going to go to

226.85 -> all the vital organs in the body,

228.62 -> the brain, the kidneys,

230.18 -> the liver, the tissue, etc.

232.81 -> You can see that there's

235.13 -> multiple areas in the heart

236.975 -> which you can develop heart failure from,

238.73 -> it could be a relaxation issue

240.845 -> or it could be a pumping issue,

242.48 -> or it could be even a valve issues or two.

245.275 -> Then the heart is a muscle,

247.2 -> the muscle needs nutrients,

249.35 -> it needs blood supply and

251.21 -> that's basically on this diagram here.

253.43 -> You can see what is called these, they are

254.69 -> called the coronary arteries.

256.115 -> These are the arteries,

257.24 -> are blood vessels that sit on top of the heart,

259.8 -> and they basically provide nutrients to the heart muscle.

263.305 -> Basically here on the left side

267.02 -> you have what's called a left main,

268.97 -> which is the main vessel that

270.11 -> splits into two vessels here.

272.27 -> On the right you have what's called the right coronary

274.82 -> artery. What is heart failure?

279 -> This slide or this picture nicely summarizes what's

282.26 -> heart failure is and we're going to come back to

284.06 -> this illustration at the end of the topic.

286.3 -> The definition of heart failure is,

287.98 -> heart failure or congestive heart failure

290.105 -> is a condition in which the heart is unable

292.7 -> to pump adequate blood flow

295.52 -> to meet the needs of the body.

297.845 -> We talked about in the last slide that the left side,

300.44 -> the pumping chamber has now

301.67 -> oxygenated blood and it provides

303.83 -> nutrients to the rest of

305.06 -> the body and so that's what heart failure basically is.

308.87 -> There's different types of heart failure.

311.12 -> The way I like to make it

313.325 -> simplified is you have basically a relaxation problem,

316.205 -> you have a stiff heart.

317.56 -> It's not failing normally.

318.98 -> We talked about the top chambers of

320.63 -> the failing chambers or you have a pump issue.

324.02 -> The bottom chambers is a workhorse

326.105 -> and they have a problem with that.

327.48 -> This is what's called diastolic or relaxation

329.96 -> heart failure and you can see

331.58 -> here the muscle is very thick.

334.555 -> As such, it doesn't fill with blood properly,

339.06 -> and this results in a buildup of blood or

342.785 -> congestion in the lungs

344.435 -> leading to heart failure and symptoms.

347.375 -> On the other side here you have what's

349.58 -> called systolic or squeezing heart failure.

351.53 -> This is when the pump is the problem,

353.395 -> and as a result of the decrease pumping on the left side,

358.055 -> blood again is going to build up back

359.99 -> in the lungs and the tissues and

361.73 -> cause symptoms and signs that we see on exam.

366.205 -> There's a lot of other causes of heart failure too.

369.155 -> This is what's called cardiomyopathies.

370.91 -> Cardiomyopathy just means disorder of the heart muscle,

374.345 -> and I'm not going to go through all of them,

375.98 -> but there's different causes, genetic causes.

378.52 -> HCM is called hypertrophic cardiomyopathy,

381.05 -> which is a thick heart.

382.295 -> Sometimes you might see this,

384.155 -> if it's an athlete that die suddenly,

387.37 -> Hank Gathers who is a basketball player

389.72 -> that died suddenly on the basketball court.

392.09 -> He had hypertrophic cardiomyopathy.

393.8 -> There's a genetic component to that.

396.805 -> Then you have some of the acquired a cardiomyopathies.

400.445 -> It could be a virus,

401.79 -> you have a virus developed

403.085 -> leading to inflammation of the heart.

405.095 -> Sometimes stress can lead to cardiomyopathy as well too,

409.2 -> peripartum women either in the last month of pregnancy or

413.06 -> first few months after pregnancy develop

415.19 -> a cardiomyopathy or a weak heart or heart failure.

418.34 -> Also fast heartbeats can

420.62 -> also develop into heart failure as well too.

422.87 -> There's lot of different causes.

425.015 -> But the risk factors are

426.65 -> causing for heart failure while we

428.18 -> expect a poor diet, smoking, etc.

432.41 -> The most common cause of heart failure is

435.89 -> coronary artery disease or

437.06 -> myocardial infarction or heart attacks basically.

440.275 -> Here basically we talked about member before.

442.685 -> You have these are the coronary arteries,

444.41 -> the blood vessels that

445.97 -> supply nutrients to the heart muscle.

448.435 -> Here you can see basically a diagram of that artery,

451.49 -> and you can see it's nice and smooth.

453.125 -> You have good blood flow.

454.795 -> Here you can see a blocked artery.

456.74 -> This could be due to diabetes or

458.63 -> high cholesterol or high blood pressure over time.

461.42 -> You have this plaque buildup basically here,

464.54 -> and this leads to decrease blood flow to

466.28 -> the heart muscle and that can lead to heart failure.

469.475 -> Myocardial infarction is basically means a heart attack.

472.94 -> Sometimes when you have this plaque forming that can

476.18 -> lead to a heart attack and this is

477.71 -> the most common cause of heart failure.

479.81 -> Here's basically an angiogram,

481.32 -> an angiogram is basically

482.33 -> an X-ray of the blood vessels in the heart.

485.065 -> Basically this is done

487.28 -> either through the groin or the risks,

489.08 -> and basically you're going to pass

490.4 -> a catheter up to the aorta,

492.455 -> which is main vessel here

493.8 -> and this is where the blood vessels,

495.59 -> the coronary arteries come off of.

497.24 -> Then they inject dye and they take

499.43 -> a look at these vessels and if you can appreciate here,

502.865 -> you can see the vessel here.

504.275 -> There's a little narrowing right here.

505.97 -> This is the area of plaque that we're

507.56 -> seeing basically in this diagram here.

510.22 -> There's other causes for heart failure as well too.

514.625 -> We talked about coronary artery disease or

517.01 -> blockages basically in the heart.

519.38 -> Heart attacks, high blood pressure.

521.84 -> How does high blood pressure cause heart failure?

523.925 -> The analogy I always like to think about is

525.74 -> like you go to the gym, you work out.

528.245 -> As your muscle gets thicker,

529.91 -> your biceps get bigger hopefully.

531.785 -> But over time eventually

533.39 -> your heart is a muscle as well too.

534.785 -> In the heart sees odd that high blood pressure over time.

537.71 -> It can sustain those high blood pressures and

540.05 -> then it just gives out and you develop heart failure.

543.145 -> Valvular heart disease basically means

545.6 -> the different valves or different doors in the heart.

547.4 -> We talked about if you have any abnormalities of

549.95 -> those valves that can lead to heart failure as well too.

553.085 -> Cardiomyopathy, we talked about those

555.2 -> are disorders of the heart muscle.

557.615 -> There's that lists we talked about.

559.19 -> Alcoholism can lead to heart failure as well too.

563.03 -> Drugs such as methamphetamine,

565.145 -> which is definitely on the rise

566.39 -> can lead to heart failure.

568.04 -> Thyroid diseases as well too,

570.47 -> infection we talked about can

572.03 -> cause an inflammation of the heart.

574.52 -> Diabetes, a fast heartbeat.

577.335 -> Then some other causes as well too,

578.84 -> is important to talk about obesity, smoking,

582.125 -> and even high or low levels

585.08 -> of blood counts and then sleep apnea.

589.21 -> Why is it important to recognize heart failure?

592.295 -> Well, because more deaths from

594.53 -> heart failure and all forms of cancer combined.

598.305 -> It's a pretty serious disease

600.12 -> and you can see here over time,

601.865 -> the number of cases is increasing about 500,000 per year.

606.515 -> In 2037, they estimate to

610.76 -> be about 10 million people

613.13 -> that suffer with heart failure.

614.645 -> The incidence is definitely increasing, and why is that?

618.035 -> We talked about the most common cause of

620.06 -> heart failure is blockages in the arteries,

623.015 -> and I think with our techniques on recognizing that and

626.27 -> doing procedures and putting

627.47 -> stents to open up those blockages.

629.555 -> People are surviving heart attacks

631.55 -> and they're living longer,

632.96 -> but they're living with heart failure.

634.66 -> You can see the case of heart failure are increasing.

638.005 -> Here is basically showing

640.04 -> that the prevalence is increasing.

641.3 -> Particularly people are living longer,

643.55 -> so the population has changed as well too.

645.5 -> It's an older population as well too.

647.51 -> The mean age of diagnosis is about 74 years of age.

651.5 -> It's a very serious disease as well too very deadly.

655.385 -> This is looking at cardiovascular mortality

658.37 -> or deaths from cardiovascular causes.

660.8 -> Majority is still coronary heart disease

662.96 -> or blockages in the arteries.

664.955 -> But a 7% is related to

667.14 -> heart failure and that leads to about

669.09 -> 300,000 deaths per year so quite a large amount.

674.37 -> Heart failure is very expensive.

676.655 -> It leads to hospitalizations and you can

680.12 -> see here the total direct costs about 31 billion in 2012.

683.705 -> You can see it's going to skyrocket

685.37 -> to 70 billion in 2030.

687.425 -> Majority of those costs related to

689.075 -> hospital care and then nursing homes as well too.

693.29 -> Classifying heart failure, we'll talk with

695.93 -> some of the terminology and staging.

698.61 -> I think this is important slide I

701.02 -> want to spend some time on.

703.105 -> We have two ways of classifying heart failure.

706.315 -> The first one is the New

707.68 -> York Heart Association Functional Class,

709.96 -> which you see on the right side

711.7 -> here and that basically is a scale 1-4.

714.985 -> Basically this assess a patient's symptoms,

717.37 -> how limited they are from their heart failure.

720.66 -> Class 1 is asymptomatic,

723.4 -> they have no symptoms and it goes all the way up to four,

725.62 -> which means they have resting shortness of

727.45 -> breath and this is very dynamic.

729.73 -> You could have a patient that you

730.99 -> diagnosed with heart failure,

732.49 -> you put them on therapies and they can be initially

736.17 -> a class 2 and then they can become a

738.63 -> two so it changes from time to time.

742.29 -> Then a couple of years ago, the ACC,

746.455 -> which stands for the American College of Cardiology

748.63 -> and the American Heart Association,

749.89 -> came up with the staging system

751.51 -> and why did they come with the staging system?

753.43 -> Because they realize that

755.62 -> there's risk factors for heart failure.

757.21 -> They want to try to prevent

758.26 -> the occurrence of heart failure.

760.465 -> Developed a staging system A through

762.64 -> D. Let's go through them.

765.04 -> These are patients that are high

766.66 -> risk for heart failure but

767.89 -> don't have any abnormalities on any testing.

771.045 -> We talked about patients who have high blood pressure,

773.235 -> patients who have blockages in the arteries.

777.635 -> Basically it clues in

780.07 -> the primary care doctors seeing

781.54 -> these patients that this patient has diabetes,

783.94 -> this patient has high blood pressure.

785.5 -> I should be aware this patient

786.64 -> has a higher chance of developing

787.75 -> heart failure than somebody that

788.95 -> does not have those conditions.

790.39 -> I should have a lower threshold

791.71 -> of looking for heart failure for this patient.

794.65 -> Stage B basically means that now

797.59 -> they have abnormalities on some type of tests,

799.96 -> a diagnostic test, but they don't

801.91 -> have any symptoms, which we'll go over.

804.55 -> Stage C is when lot of patients present.

807.145 -> Now they come to the hospital with

808.96 -> shortness of breath and they

810.94 -> have abnormality on testing

815.005 -> and then stage D is a late stage.

818.395 -> This slide basically goes over the pathophysiology.

823.165 -> I'll simplify basically,

824.77 -> but I think it brings a good point

827.26 -> that it starts with prevention

828.85 -> basically so you have these preventable diseases,

831.46 -> high blood pressure,

832.78 -> blockages in the heart,

835.58 -> valvular disease, or abnormalities of

837.6 -> those valves in the heart, obesity, diabetes, etc.

841.815 -> You're trying to optimize these conditions,

844.72 -> but over time it can lead to abnormalities in

847.9 -> the heart leading to certain abnormal process that occur,

851.395 -> leading to development of some structural abnormality,

854.62 -> could be a stiff heart or

856.27 -> a pumping problem and that

858.085 -> automatically now you're a stage B.

859.96 -> These patients have some abnormality in the heart,

862.24 -> but they don't have any symptoms

863.875 -> and then over time they can

865.72 -> develop symptoms and now they are

867.22 -> state C and then it progresses.

870.025 -> With the staging system A through D,

872.395 -> you can go back and forth.

874.465 -> Basically what we're trying to do is at stage A,

877.54 -> we're trying to really

879.385 -> emphasize that reduction of high blood pressure,

884.05 -> controlling blood pressure, diabetes, etc.

887.605 -> This can hopefully slow this progression,

890.74 -> basically or halt it.

893.61 -> When should you go see the doctor?

896.845 -> Hopefully it's not as obvious as this.

899.065 -> So what are the signs and symptoms of heart failure?

902.17 -> We talked about you could either have a problem with

904.66 -> relaxation or a problem with pumping.

907.03 -> But the net effect is the same like you mentioned,

909.565 -> is you get congestion in the lungs and the body.

913.555 -> Let's go through this. You'll be restless.

916.36 -> Obviously you have lot of fluid buildup,

918.16 -> so you're going to be anxious.

919.765 -> You might have some confusion. Why is that?

921.97 -> Because your heart if is not pumping adequately,

924.37 -> you might need good blood flow to the brain.

927.325 -> Orthopnea basically means that

929.785 -> at night you'll be sleeping with extra pills at night.

932.05 -> You can't lie flat because when you lie flat you

934.06 -> get more congestion in the heart.

936.37 -> A lot of our patients say they can't sleep flat at

938.71 -> night then use pillows or sleeping at chair.

941.665 -> Exertional dyspnea.

943.48 -> When they walk, they get shortness of

945.22 -> breath with limited distances.

947.485 -> Fatigue could be a sign that the heart is very weak.

951.16 -> Then as a result of

952.975 -> congestion in the lungs, they'll have a cough.

955.15 -> Usually it's a dry cough,

956.29 -> it's worse at night.

958.03 -> They might have some signs on exam when we

960.52 -> listen to them with a stethoscope,

963.445 -> they might have crackles,

965.05 -> which a certain sound we listen to,

966.52 -> which represents fluid in

967.9 -> the lungs and their respiratory rate might be elevated.

972.31 -> And something called paroxysmal nocturnal dyspnea.

975.37 -> This basically means that patients will wake

977.14 -> up at night gasping for air.

979.255 -> Sometimes they'll say they need to go to

980.65 -> a window to catch their breath.

982.255 -> This is all a sign that they have lot of congestion in

984.34 -> the lungs and signs for heart failure.

987.89 -> How is heart failure diagnosed.

990.72 -> First of all, you take

991.89 -> a good medical history and what is good medical history?

994.56 -> First of all, I ask for questions about risk factors,

998.115 -> are they diabetic, do they have high blood pressure,

1000.59 -> any drug history to clue you in how high is

1004.86 -> your suspicion for this patient having

1006.48 -> heart failure and then you do an exam, a physical exam.

1010.17 -> A lot of times,

1011.535 -> many of you know someone with heart failure,

1013.92 -> we always look at the neck and why are we doing that?

1016.62 -> We have what's called a vein here,

1018.15 -> the internal jugular vein,

1019.635 -> which is like a dip stick that

1020.97 -> drains right into the heart.

1022.44 -> You can imagine if a patient has backup of fluid,

1026.135 -> it's going to become very

1028.07 -> prominent and that's what we're going to see on our exam.

1031.27 -> You can also have swelling of the feet as well too,

1035.64 -> or the abdomen and that's what you're seeing here,

1037.41 -> normal and you can see swelling of this leg here.

1040.485 -> There are certain labs that we do as well too.

1043.41 -> We do a CBC or blood count.

1045.15 -> We want to see what the hemoglobin is because if you have

1047.19 -> a high hemoglobin that can lead to heart failure,

1049.59 -> a chemistry panel is going to look at

1051.18 -> your kidney function because that

1052.53 -> might be affected by heart failure.

1054.69 -> We do a BNP, which is

1057 -> a blood test that's elevated when you have a lot of

1059.01 -> congestion so it helps clue in whether

1061.17 -> this patient is likely to have heart failure or not.

1064.215 -> A TSH, which is the thyroid tests.

1067.02 -> HIV, iron studies,

1068.67 -> a patient has iron overload.

1070.71 -> Too much iron in the body that can

1072.45 -> lead to heart failure as well

1074.13 -> too and then there's

1075.45 -> some testing for specific populations.

1078.15 -> Iron, we talked about sleep studies.

1080.01 -> Sleep apnea, which is increasing,

1082.365 -> is a very common cause for

1084.51 -> heart failure and can be potentially treated

1086.7 -> if you have a patient on

1088.56 -> CPAP or certain therapy for sleep apnea.

1091.59 -> There are certain proteins that deposit in the heart.

1094.26 -> There are certain testing we can do for that as well

1096.12 -> too and then there's some heart failures,

1098.61 -> that's genetics so there can be

1099.96 -> genetic screen can be done as well too.

1101.805 -> What is BNP.

1103.5 -> BNP is actually a blood test that when the heart is

1106.98 -> stretched or congested will go up.

1112.22 -> The troubling is when your patient comes,

1115.71 -> let's say to emergency room and

1117.21 -> patient is shortness of breath,

1118.74 -> you're trying because it from the heart,

1119.85 -> is it from the lungs And sometimes you can use a BNP

1122.91 -> as a blood test to see if it's

1124.32 -> from the heart versus the lungs.

1126.285 -> That differentiate between the two.

1128.43 -> What does it stand for?

1130.545 -> It's basic natriuretic peptide.

1136.22 -> EKG as well too can be

1139.65 -> a clue in that there's something wrong with the heart.

1142.47 -> That could be your first sign as well too.

1145.2 -> Chest X-ray.

1147.435 -> Here's your lungs basically here and this

1149.79 -> is the heart silhouette here.

1151.77 -> You can see the lungs are clear, they're aerated.

1154.455 -> This is a patient with heart failure.

1156.45 -> I don't know if you can appreciate here,

1157.62 -> but if you look at

1158.13 -> the size here versus here,

1160.17 -> this heart is very enlarged and you can see the lungs.

1163.935 -> This is all filled with fluid.

1165.36 -> That's why it has

1166.8 -> the appearance of the widest appearance,

1169.32 -> which this is all air and this is all filled with fluid.

1173.51 -> Really the gold standard is an echocardiogram.

1177.09 -> This is an ultrasound.

1178.86 -> If you remember the anatomy pictures we talked about,

1183.42 -> you have the pumping chambers

1184.77 -> and you have the filling chambers.

1186.615 -> We'll just focus on the pumping chambers here.

1188.64 -> This is the left side,

1189.93 -> this is the right side. You can appreciate here.

1192.63 -> This left side here is nicely coming in.

1195.24 -> It's pumping nice and normal.

1197.715 -> Here's a patient with heart failure.

1199.77 -> This is what's called systolic heart failure.

1201.615 -> You can see the chamber here is quite enlarged

1204.09 -> compared to here and you can see the function,

1207.21 -> the matter that is coming in is reduced.

1209.64 -> This patient has systolic heart failure.

1211.77 -> The echo is really the gold standard.

1213.27 -> It can tell us a lot information.

1214.575 -> It can tell us the pumping ability of the heart

1216.57 -> and also you can see the valves here.

1218.52 -> We talked about those doors

1219.915 -> that separate the different chambers.

1221.52 -> You can also see if there's

1222.54 -> any leakage at this valve as well too.

1226.37 -> The echo is a key indicator for diagnosing heart failure.

1231.705 -> It'll tell you what's called an ejection fraction,

1233.7 -> which is the amount of blood that's pumped

1235.53 -> out of your heart with each heartbeat.

1237.735 -> It's important to evaluate

1239.43 -> cardiac function and also reflects

1241.29 -> the strength of the ventricular contraction

1243.15 -> or the left ventricle contracting.

1245.745 -> Sometimes imaging is done

1247.89 -> as well too for certain conditions.

1249.48 -> We said heart failure has many different causes.

1251.835 -> Some causes are due to a protein deposit,

1254.43 -> and you can do a cardiac MRI to look for

1256.05 -> that and also nuclear imaging as well too.

1259.82 -> Some type of workup for looking for blockage of

1262.86 -> the heart has to be done because we talked,

1264.93 -> that's the most common cause.

1266.16 -> Many times patients will undergo

1267.69 -> a catheterization where we actually inject

1270.3 -> dye to look at the blood vessels and making

1272.25 -> sure there's no abnormalities.

1274.965 -> Because theoretically, if there's any abnormalities,

1277.47 -> if we're able to restore the blood flow,

1279.45 -> now you have more nutrients to

1280.74 -> the heart muscle and

1281.88 -> the heart muscle can actually improve.

1283.365 -> This is a reversible cause potentially of heart failure.

1287.58 -> In summary, came back to this picture again.

1293.25 -> What is heart failure? It's a disorder of the heart.

1297.015 -> Prevention is key.

1298.92 -> We talked about the certain risk factors

1300.48 -> that you have a higher chance of having heart failure.

1303.87 -> The signs and symptoms are related to

1305.46 -> congestion or decreased output.

1308.04 -> If you can see here on the slide,

1310.32 -> this nice illustrate, you can see

1311.85 -> this heart here is enlarged.

1314.55 -> He's having a lot of trouble breathing

1316.62 -> here and as you can see some sweat coming down his brow.

1320.175 -> This nicely summarize really

1321.81 -> what patients feel like when they

1323.13 -> have heart failure and

1324.6 -> some of the patterns that they see.

1326.52 -> With that, we'll continue on to the next talk and we'll

1330.06 -> have questions at the end [APPLAUSE]

1339.72 -> Hi, everyone. Thanks for coming. My name is Vance Selby.

1341.91 -> I'm also part of the Advanced Heart Failure program,

1344.025 -> along with Dr. John Mohamed.

1345.84 -> I have a little bit of a broad topic to talk about today.

1348.39 -> It's basically treatment of heart failure,

1350.565 -> and we're really going to be focusing on

1352.2 -> what he referred to as the stage C patients,

1355.08 -> the patients who have

1355.62 -> developed symptomatic heart failure,

1357.48 -> whether it be due to systolic dysfunction

1359.28 -> or diastolic dysfunction.

1361.215 -> I'm going to try to go over a fair number

1363.9 -> of topics because there's

1365.475 -> a lot of different ways we treat

1366.78 -> heart failure and then if there are any questions,

1369.66 -> like he's just said, we'll have time at the end.

1373.125 -> Well, first I'll talk about the goals

1375.21 -> of heart failure treatment.

1376.23 -> It's very important to set goals

1377.55 -> and understand your priorities,

1378.75 -> whether you're the patient or the treating physician,

1381.09 -> you need to know what you're trying to accomplish.

1383.235 -> Then we'll get into some of the specific things.

1385.575 -> We often start with lifestyle modification,

1387.81 -> whether that'd be diet, exercise,

1389.76 -> whatever it is that they can help patients feel

1391.89 -> better and hopefully do better.

1394.14 -> Then we'll get onto medical therapy for heart failure.

1396.27 -> There are about five or six different types

1397.98 -> of medications we'll go over.

1399.405 -> Then we'll talk about some devices for patients who still

1402 -> have symptoms despite the best medications.

1405.585 -> What are the goals of treatment if you're a patient with

1408.72 -> heart failure or a provider who's treating it?

1411.33 -> Well, the first thing is to relieve symptoms.

1413.565 -> You just heard

1414.42 -> all the different symptoms of heart failure,

1415.89 -> whether it's shortness of breath,

1417.3 -> swelling, fatigue, what have you.

1420.705 -> The symptoms are broad

1422.25 -> and we want to make patients feel better.

1423.9 -> It's a condition that really impacts

1425.82 -> the quality of life for our patients and we

1428.01 -> have some medications that can be very effective

1429.84 -> for relieving those symptoms.

1432.645 -> The second is to slow disease progression.

1435.39 -> You saw some echos of some weak hearts,

1437.91 -> some hearts that are starting to get big

1439.17 -> and dilated over time.

1441.345 -> We like to reverse and maybe even improve that function

1445.23 -> with medications and we do have

1447.21 -> a few that are capable of that.

1449.565 -> We want to reduce hospitalizations

1451.56 -> and emergency room visits.

1452.955 -> Hospitalizations are considered a bad sign in

1456.03 -> heart failure and a sign that

1457.56 -> a patient is not doing as well as they should be,

1459.45 -> so you see a lot of

1461.01 -> effort going into keeping patients out

1462.72 -> of the hospital as much as possible.

1466.365 -> Finally, ideally,

1468 -> we have medications that will prolong life

1470.52 -> and with proven ability to make

1473.64 -> people live longer compared to

1474.93 -> patients who don't get that medication.

1476.88 -> That's usually one of our biggest goals as providers,

1480.09 -> is to prolong life,

1481.32 -> and for most patients,

1482.67 -> I'd say that's one of the biggest goals.

1484.2 -> Though there are some patients who really want to

1485.76 -> focus on symptom relief more than

1487.83 -> life prolongation and it's very important to just have

1491.13 -> that discussion and reach an understanding

1492.69 -> of what you're trying to do with your treatment.

1496.22 -> The first thing when you have a patient

1498.42 -> with heart failure in terms of

1499.59 -> treating it is is there some underlying cause I can fix?

1502.98 -> You just saw a few of them.

1504.795 -> Coronary artery disease, we always look for

1507.18 -> this in just about every patient with heart failure,

1509.865 -> partly because if you find it,

1511.29 -> you can often fix it.

1513.06 -> The two acronyms in there or CABG,

1515.055 -> coronary artery bypass graft surgery,

1517.23 -> and then PCI is percutaneous coronary intervention,

1520.305 -> also known as stents.

1521.745 -> Like Dr. John Mohamed said,

1523.185 -> if you open up the blocked arteries

1525.6 -> and restore blood flow to the heart,

1527.04 -> you can oftentimes improve the function,

1528.855 -> improves symptoms and patients will do better overall.

1532.125 -> Hypertension is a common cause of heart failure,

1535.11 -> so we obviously tried to treat that

1536.865 -> as best we can in anyone with heart failure.

1539.7 -> We do that through both medications

1541.47 -> and diet as we'll get to.

1542.97 -> Valvular heart disease.

1544.545 -> You may have heard of conditions like

1545.865 -> aortic stenosis, mitral regurgitation,

1548.52 -> they're valves that are either not opening

1550.62 -> properly or not closing properly and so they leak.

1553.785 -> Those are common causes of heart failure

1555.945 -> and oftentimes if detected early enough,

1558.9 -> you can repair or replace

1560.58 -> the diseased valve and the heart will get better.

1563.805 -> Some patients are born with heart defects.

1565.935 -> We call that congenital heart disease.

1567.975 -> Sometimes you can repair those surgically or through

1571.71 -> catheters that go into veins and arteries in the body.

1575.49 -> Fixing those will often help

1576.84 -> the heart function if that's the cause.

1578.67 -> Then we also want to just aggressively treat

1581.34 -> any condition that might be

1582.45 -> contributing or causing the heart failure,

1584.25 -> so diabetes, anemia, sleep apnea.

1586.71 -> It's really important to

1588.105 -> aggressively control these comorbidities.

1592.21 -> Now we're going to get onto other specific treatments

1595.43 -> for heart failure itself,

1596.75 -> but as we do, I want you to just keep this in mind,

1599.48 -> so like I said,

1600.68 -> causes of hospitalization for

1603.53 -> heart failure is something that really tried to avoid,

1605.915 -> we considered a bad outcome

1607.46 -> when a patient is hospitalized,

1608.885 -> and this is a list of the most common causes.

1611.665 -> We're going to talk about diet.

1613.41 -> We can often find dietary triggers in this study,

1617.415 -> almost a quarter of all

1618.63 -> heart failure hospitalizations patients

1621.78 -> not taking their medications as prescribed.

1624.12 -> Another big cause, so we'll talk

1625.56 -> about the medications to take,

1627.63 -> failure to seek care.

1629.4 -> I'm going to go over some of the symptoms and signs

1631.59 -> that you need to contact medical therapy,

1633.915 -> and then inappropriate therapy,

1636.675 -> which is often on the part of

1638.73 -> the prescribing physician or

1640.725 -> nurse or whoever is taking care of the patient,

1642.675 -> and so we'll go over some of the medications we use.

1644.925 -> By the end, we'll have addressed

1646.86 -> really the main causes to

1649.23 -> bad outcomes in patients with heart failure.

1652.76 -> First, we'll start with diet.

1655.365 -> Some of this stuff is very targeted

1656.91 -> toward patients with heart failure,

1658.35 -> I know many in the room don't have heart failure,

1660.33 -> but actually a lot of these things are

1661.59 -> good to keep in mind in general.

1663.135 -> Sodium is one of

1665.64 -> mine and a lot of cardiologists biggest pet peeves,

1668.01 -> in heart failure just wreaks havoc on the body.

1670.365 -> It really causes you to retain

1672.27 -> extra fluid leading to that swelling,

1674.58 -> whether it be in the lungs, the legs, whatever.

1677.715 -> It also increases the blood pressure which

1679.62 -> makes the heart have to work harder.

1681.6 -> It's really just oftentimes the bane of our existence.

1684.975 -> I can't tell you how many times

1686.19 -> the patient will come into

1687.36 -> the clinic or the emergency department

1689.085 -> totally swollen with fluid,

1690.585 -> and then you find it was

1692.07 -> either some chicken wings or a can of soup or

1695.01 -> something that they ate a day or two ago and

1697.05 -> just started retaining fluid ever since then.

1699.945 -> That said it's not just heart failure patients,

1702.915 -> especially if you have high blood pressure,

1704.835 -> but even just the general population,

1706.56 -> there's some evidence coming out that

1708.75 -> just higher sodium diets are linked

1711.15 -> to death in just broad populations,

1713.61 -> whether it be from stroke or heart disease or something,

1716.22 -> there's a good correlation now

1717.84 -> between a dietary sodium intake and bad outcomes.

1720.765 -> Whether or not you have heart failure,

1722.01 -> you should pay attention

1724.125 -> and try to incorporate these as best as you can.

1727.215 -> Two thousand milligrams a day

1729.3 -> is the rough consensus opinion,

1731.31 -> different societies will have different recommendations.

1734.19 -> But I think that it's not impossibly strict,

1737.265 -> if you tell a patient eat 500 milligrams of sodium a day,

1740.16 -> there's no way they can do it.

1741.655 -> But I think it finds it acceptable balance.

1745.76 -> One teaspoon of salt is 2,300 milligrams of sodium,

1749.21 -> this isn't a lot of salt that

1751.01 -> I'm saying you should be eating,

1752.57 -> so something to keep in mind.

1754.89 -> How much of a bag of chips?

1756.605 -> It depends on the chips,

1758.82 -> but my guess would be at least 400 milligrams or so.

1762.045 -> Chips are a great source of salt

1763.62 -> and I mean that in a bad way, of course.

1766.53 -> But we'll talk about label reading,

1769.59 -> which is the most important skill you could

1771.27 -> take when it comes to diet.

1773.49 -> A lot of patients say cutting down

1775.11 -> on salt is really hard at first,

1776.46 -> but eventually you get used to it,

1778.38 -> your taste buds adapt to the lower salt foods.

1780.96 -> Some patients even say they start

1782.22 -> to appreciate new flavors that

1783.585 -> they used to just drown out with salt, so it is doable.

1786.915 -> Then watching your fluid intake,

1789.72 -> and that's really something that

1791.985 -> heart failure patients can discuss with

1793.32 -> their doctors in terms of exactly how much they take.

1795.615 -> But it makes sense that if you drink six liters of fluid,

1798.15 -> you're more likely to build it up in

1799.71 -> the lungs or in your legs or your belly or wherever.

1804.615 -> We tried to watch that.

1806.79 -> I've got to drive home the point on sodium a little bit.

1810.15 -> Packaged foods are just a horrendous source of sodium,

1813.09 -> so whether that'd be chips or

1814.845 -> a pack of noodles or a can of soup,

1817.605 -> they're just all full of sodium.

1819.39 -> Cooking for yourself as much as you can,

1821.265 -> especially if you have heart failure,

1822.6 -> it's really important to get into it.

1824.67 -> I'll show you some labels in a second.

1826.5 -> Eating fresh foods and fruits and vegetables,

1828.585 -> even eating just fresh meat,

1829.89 -> it's much better than packaged.

1831.78 -> Don't use a salt shaker,

1833.235 -> try using herbs and spices whenever you can to cook.

1835.77 -> Condiments, especially things like

1837.33 -> soy sauce or some of the other things you've seen in

1839.73 -> restaurants can really be sources of sodium.

1844.08 -> There are a lot of low salt cookbooks out there,

1846.03 -> this is one from the American Heart Association.

1847.89 -> But if you just Google low salt cooking,

1850.665 -> there are lots of things that come up and you can find

1852.93 -> lists of ways to cut salt out of your diet.

1856.44 -> Then you've got to learn how to read labels.

1858.81 -> This is from a can of soup,

1860.535 -> so for one cup,

1862.605 -> 1080 milligrams of sodium.

1864.855 -> You've taken about half-year daily intake

1866.97 -> it with just one small can of soup.

1868.695 -> That's what I mean by packaged foods.

1870.54 -> This is another slide that doesn't come out great,

1873.39 -> but it says it's 77% of

1875.31 -> the sodium and food is from the processing unit.

1877.47 -> They take low salt natural ingredients

1879.81 -> packaged into a can of soup or what have you,

1882.36 -> and that's where it gets most of its sodium,

1884.49 -> and so that leads to

1885.93 -> my recommendation of cooking on your own as much

1888.18 -> as possible where you know

1889.26 -> exactly how much sodium is going

1890.85 -> in and you're starting with fresh ingredients.

1893.545 -> Lifestyle modifications.

1895.94 -> You'll see recommendations of

1897.26 -> usually about 30-45 minutes a day,

1899.435 -> that can be tough for a heart

1900.71 -> failure patient who's really limited.

1902.825 -> But it's a good goal to strive for five days a week,

1906.7 -> especially if you have heart disease,

1908.58 -> it's important to talk to your doctor first,

1910.74 -> just make sure what you're doing is acceptable

1912.72 -> and that you're not pushing yourself too hard.

1914.865 -> Then for those cardiac patients out

1917.34 -> there or anyone who

1920.43 -> has friends or family who have heart disease,

1921.945 -> I'd really make a plug

1923.31 -> to consider cardiac rehabilitation.

1925.17 -> I'm a huge fan of it.

1926.97 -> This is an idealized picture

1929.46 -> of what goes on at cardiac rehab,

1930.96 -> where you're exercising but you're constantly monitored.

1934.035 -> You're being given a very specific exercise regimen

1938.19 -> catered to your disease.

1940.005 -> I find a lot of patients come to me and say, well,

1942.93 -> I'm really scared to exercise

1944.31 -> because I don't want to overdo it,

1945.51 -> I don't want to trigger a heart attack,

1946.905 -> I don't want to trigger a dangerous rhythm.

1948.72 -> This is a nice way to alleviate that and let

1951.78 -> them build up their exercise while constantly monitored.

1955.635 -> If you have heart disease, talk to your doctor

1957.72 -> about cardiac rehab.

1959.78 -> Other good lifestyle modifications,

1962.28 -> and here's where we get really specific things

1964.23 -> for people with heart failure.

1965.535 -> We tell them check your weight every morning.

1967.53 -> Increase in weight is

1969.27 -> a suggestion that you are starting to retain fluid,

1971.67 -> and so we tell patients to really watch

1973.2 -> out for that closely and they call

1974.7 -> their doctor if they start to gain any weight.

1977.835 -> I really like to tell people what their dry weight is,

1980.37 -> meaning when you don't have

1981.54 -> extra fluid, this is your weight.

1983.085 -> This is where I want you to be,

1984.42 -> if you gained three pounds above that,

1986.01 -> call the office, and we'll talk about what you can do.

1988.65 -> Making sure you take meds regularly,

1990.795 -> you might remember that medication non-adherence

1993.39 -> was about 20% of

1994.56 -> the contributors to hospitalizations

1997.365 -> and then keeping track of symptoms.

1999.495 -> Again, another common cause from that graph I showed at

2002.72 -> the beginning was patient's

2004.82 -> not seeking care when appropriate.

2007.115 -> If you're swelling up more,

2008.375 -> if you're more short of breath,

2009.425 -> if you can't sleep flat, any of these things,

2012.56 -> I think you already saw a slide very similar

2014.06 -> to this but swelling,

2016.61 -> coughing, trouble breathing, chest pain,

2019.01 -> confusion, seek medical care because that's a sign that

2022.13 -> something's going wrong and you want

2023.87 -> to address it quickly.

2026.735 -> Other little things. You just good overall healthy diet,

2030.05 -> losing weight if you're obese, quitting smoking,

2032.315 -> all this stuff just helps the whole cardiovascular system

2035.12 -> and makes the body work more efficiently.

2039.71 -> Getting your vaccinations, and

2040.94 -> then alcohol in moderation.

2044.045 -> Alcohol increases the blood pressure.

2046.46 -> It can predispose you to retaining fluids,

2048.62 -> so really avoid it in excess.

2051.86 -> Alcohol is also a cause

2053.48 -> of heart failure in some patients,

2054.8 -> and if that's the case,

2056.18 -> then we usually recommend completely avoiding

2058.01 -> it so that the heart can heal up.

2060.44 -> Onto medical therapy.

2062.48 -> What are the goals of medical therapy?

2064.34 -> Well, we want to get rid of excess water and

2066.47 -> prevent patients from getting

2067.52 -> too swollen and uncomfortable.

2069.305 -> We'd like to use vasodilators.

2070.97 -> These are medications that relax the blood vessels.

2074.06 -> Dr. John Mohamed talked about how in

2076.31 -> high blood pressure you really

2077.63 -> increase their work the hardest to do.

2079.505 -> Well, if you relax those blood vessels,

2081.68 -> then you decrease the work the heart has to

2083.42 -> do and it can work more efficiently.

2085.895 -> As Dr. John Mohamed showed in the previous slide,

2088.985 -> there are a lot of hormones produced in

2090.59 -> heart failure that lead to some of the problems,

2092.96 -> whether it be thickening of the heart

2094.79 -> or dilation and weakening of the heart,

2097.235 -> so we have some medications that

2098.63 -> can target those hormones

2099.95 -> that the heart produces in response to heart failure,

2103.325 -> and those can really be effective for

2105.095 -> reversing or at least slowing down the progression.

2107.555 -> Then finally, there's some medications

2109.04 -> that help the heart squeeze better.

2111.44 -> We're going to about one slide per class of medication,

2114.68 -> and these are complicated medication,

2117.2 -> so I'll try to just hit the highlights.

2119.51 -> Diuretics are medication that

2121.835 -> almost every heart failure patient ends up on,

2124.55 -> and it's often the first thing they get put on.

2126.6 -> Diuretics are medications that help you get rid of fluid.

2129.58 -> So they block various areas in

2132.79 -> the kidneys and increase

2135.34 -> the amount of water that's secreted.

2137.155 -> Some of the most common ones are Lasix, Bumex, Diuril.

2141.435 -> One thing I really like to do is get a patient on them,

2145.18 -> but then also tell them that they can

2146.35 -> adjust it as needed.

2147.775 -> Say you weigh yourself one day and your weights up

2150.01 -> three pounds and maybe you're a little more swollen,

2152.08 -> you can take an extra dose of lasix that day

2154.255 -> or you can call my office and we'll tell you to take it.

2156.675 -> But it's nice to just adjust it to keep

2158.54 -> patients at that dry weight as best as possible.

2161.765 -> Other tips just if you have heart failure,

2164.705 -> sometimes people stop taking their evening dose

2166.73 -> because it keeps them up all

2167.6 -> night going to the bathroom,

2168.56 -> you can take it early in the afternoon

2170.12 -> and you won't have that problem.

2172.64 -> These are the medical therapies that are shown

2175.16 -> to improve harder outcomes in patients,

2178.1 -> and by that I mean they either reduce hospitalizations,

2180.32 -> improve mortality, or both.

2183.335 -> You'll see for systolic heart failure,

2185.06 -> we have a lot of different classes and I'll get to them.

2187.31 -> Unfortunately for diastolic heart failure,

2189.725 -> and I also use this acronym here, HFpEF,

2191.75 -> Heart Failure with Preserved Ejection Fraction,

2194.045 -> meaning that ejection fraction,

2195.83 -> which is the amount the heart squeezes, is still normal.

2198.695 -> There's really no therapy that's clearly

2200.66 -> proven to reduce mortality.

2204.34 -> Just bear in mind, all of these are

2206.81 -> specifically for systolic heart failure,

2208.91 -> people with reduced ejection fractions.

2211.04 -> I'm going to go through in the order that they

2212.54 -> were discovered to be beneficial.

2214.49 -> ACE inhibitors are the cornerstone

2216.83 -> of good medical management for systolic heart failure.

2219.935 -> We've known that for a long time now.

2221.78 -> I always try to get my patients on them.

2223.925 -> These are medications that end in pril.

2225.98 -> You'll hear about Lisinopril, enalapril,

2228.59 -> captopril, bonazopril, Ramapril.

2232.835 -> They all sound like that.

2235.115 -> They're blood pressure medications,

2236.99 -> so they do relax the blood vessels,

2238.865 -> but they also block

2240.02 -> the production of some of these hormones that we talked

2241.97 -> about that lead to thickening

2243.59 -> and weakening and eventually failure

2245.48 -> of the ventricles.

2246.875 -> They target that what we call the neurohormonal.

2250.055 -> They are hormones that are produced

2251.525 -> that cause a lot of the damage of heart failure.

2254.99 -> We know from many large trials now that they improve

2258.02 -> heart function so they can improve

2259.31 -> the ejection fraction They can make people feel better,

2261.68 -> keep them out of the hospital and improve survival.

2264.155 -> I'm not going to show a lot of graphs from

2266.945 -> particular trials because I don't think

2268.85 -> there's really time to go into all the results,

2271.025 -> but this is just one of the early trials

2272.915 -> of an ACE inhibitor.

2273.995 -> They tested enalapril.

2275.345 -> You don't see it as much these days,

2276.89 -> but it's one of the ACE inhibitors versus placebo.

2279.83 -> What we have here is basically death,

2283.445 -> so from zero to,

2285.41 -> it goes up to 80% of

2287.33 -> all the patients dead in the study and overtime.

2290.375 -> You see that patients who are in enalapril,

2292.25 -> far fewer at the end of this study,

2294.92 -> about 20% fewer are

2297.02 -> dead than the patients who are in the placebo group.

2299.51 -> It doesn't completely fix the problem.

2301.49 -> We still have about 40% of patients dying at a year,

2306.11 -> which is a lot,

2307.295 -> but it's much better than the placebo.

2310.505 -> What does ACE stand for?

2313.59 -> ACE. It stands for, angiotensin converting enzyme.

2316.145 -> It's basically one of

2317.78 -> the enzymes in the pathway that leads

2319.4 -> to these hormones that then cause damage to the heart.

2323.135 -> Angiotensin converting enzyme.

2325.865 -> These medications inhibit that enzyme,

2328.4 -> so prevent it from breaking down the hormones.

2333.15 -> There's also a class of medications

2335.56 -> called ARBs, angiotensin receptor blockers.

2338.155 -> We usually end up using those in patients who

2340.09 -> for some reason can't take ACE inhibitors.

2343.53 -> What would be the reason?

2345.355 -> A cough is actually the most common.

2347.875 -> I'd say the most common side effects

2349.18 -> of ACE inhibitors is cough.

2351.34 -> Sometimes patients who develop

2353.62 -> it with an ACE inhibitor will then do

2355 -> fine on the angiotensin receptor blocker

2357.225 -> and they are good medications.

2358.52 -> We just don't have as robust of data supporting them.

2361.34 -> We like to think that ACE inhibitors are really

2363.515 -> the ideal medication for heart failure. Other things.

2367.655 -> Sometimes in patients with

2368.96 -> kidney disease or high potassium,

2370.61 -> you also have to be careful with the ACE inhibitor.

2372.65 -> Also, if the blood pressure is low,

2374.255 -> that ends up being something that really limits

2376.67 -> our ability to use these medications because like I said,

2379.49 -> they do relax the blood vessels

2380.87 -> and therefore lower blood pressure.

2384.1 -> The next class of medications that was discovered

2387.38 -> for systolic heart failure is called beta-blockers.

2390.635 -> The ones that we specifically like in

2392.48 -> heart failure, coreg or carvedilol,

2394.61 -> toprol or metoprolol and bisoprolol. There are others.

2399.14 -> If you or someone you know, has

2400.64 -> heart failure and they're not on one of these three,

2402.995 -> you might want to ask if they

2404.51 -> can be changed or why they're not on them.

2406.505 -> They have a couple of effects.

2408.95 -> They do decrease what are called catecholamines,

2411.14 -> which are again one of these hormones that

2412.58 -> are produced in response to heart failure.

2415.835 -> It revs up the sympathetic nervous system

2418.985 -> and Beta-blockers undo that

2421.07 -> and some of the untoward effects of it.

2423.005 -> They also slow the heart rate.

2424.46 -> They are also blood pressure medication.

2426.26 -> Again, sometimes there'll be limited with

2427.82 -> these by issues with blood pressure.

2430.61 -> We know again from very large,

2432.62 -> very good trials, they improve heart function,

2434.36 -> reduce hospitalizations, and increase

2436.19 -> survival in heart failure with systolic dysfunction.

2439.145 -> Whether beta-blockers or ACE inhibitors

2441.86 -> is better, it's hard to say.

2443.225 -> ACE inhibitors were discovered first,

2445.22 -> so usually we get patients on

2447.08 -> some ACE inhibitor and then

2448.685 -> this is almost always the second drug we had.

2452.62 -> The third big discovery and the third step forward in

2455.96 -> the medical management of

2457.04 -> heart failure was aldosterone antagonists.

2459.17 -> Again, this is actually a diuretic,

2461.33 -> but one of its effects is to

2463.235 -> inhibit the action of a hormone called aldosterone,

2465.77 -> which is one of the key hormones in

2467.78 -> this whole hormonal cascade

2470.255 -> that causes the damage in heart failure.

2472.685 -> Again, it's for heart failure, systolic dysfunction.

2475.205 -> The two meds, spironolactone

2476.99 -> and eplerenone that are approved.

2479.09 -> These really even more than the ACE inhibitors can be

2482 -> risky in people with bad kidney disease

2483.92 -> or high potassium.

2485.87 -> If you have really bad kidney disease

2489.11 -> or really high potassium levels,

2490.34 -> you probably shouldn't be on them in the first place.

2492.08 -> But if you do get started on them,

2493.91 -> it's really important to monitor the levels

2495.92 -> of potassium and kidney function in the blood.

2498.845 -> Because if potassium gets too high,

2500.33 -> it can be a really dangerous situation.

2502.715 -> The last class of

2507.38 -> medications I'm going to talk about

2508.4 -> is hydralazine and nitrates.

2510.005 -> This is just a combination of

2511.7 -> two different medications that both relax

2513.8 -> the blood vessels so it lets

2515.33 -> the heart beat more efficiently.

2518.33 -> One relaxes the arteries,

2520.055 -> one relaxes the veins.

2521.735 -> This is a really interesting combination

2524 -> of medications because it was

2525.08 -> specifically shown to benefit African-American patients.

2528.26 -> We don't usually do

2530.105 -> clinical trials looking at specific racial groups,

2534.38 -> but there was some kind of

2535.76 -> genetic and scientific evidence

2537.29 -> to suggest they may particularly benefit from it.

2540.395 -> They studied this combination

2542.165 -> of patients who are of note,

2543.77 -> we're already taking an ACE inhibitor and

2545.63 -> many times some of the other medications I talked about.

2548.435 -> With this medication added,

2551.045 -> the combination was shown to improve symptoms

2553.22 -> and survival in these patients.

2555.2 -> It's a good option for African-American

2557.09 -> patients with heart failure due to

2558.74 -> systolic dysfunction who are already

2560.69 -> on good medical therapy for heart failure.

2563.045 -> If they still have blood pressure room left,

2565.13 -> we will tend to add this class of medications.

2569.65 -> It's one of the few medications we use

2572.285 -> that's got a race-based indication.

2575.42 -> Digoxin or digitalis is

2577.46 -> one of the oldest heart failure medications.

2579.32 -> It originally was identified in

2580.58 -> the foxglove plant, which you see here.

2582.83 -> Basically it just helps the heart squeeze stronger.

2586.805 -> It acts on one of the ion channels in

2590.36 -> the heart membrane and leads to increased levels of ATP,

2593.96 -> which is the fuel the heart needs to contract.

2598.955 -> It increases contractions.

2600.32 -> The main thing to know about it is it reduces symptoms.

2603.185 -> It probably helps keep people out of the hospital,

2605.54 -> but has no effect on survival.

2607.295 -> The other four classes

2610.16 -> of medications we went over all improved survival.

2612.32 -> Digoxin has not been shown to.

2614.105 -> It also requires monitoring of levels

2616.31 -> and if the levels get too high,

2618.32 -> it can become dangerous.

2619.475 -> Oftentimes causing the heart to beat

2620.96 -> irregularly and sometimes in dangerous ways.

2623.705 -> It can be great for some patients as long as you

2626.24 -> are careful with your selection and monitor closely.

2630.25 -> Medical therapy of diastolic heart failure.

2633.305 -> Like I said, nothing has been shown to improve survival.

2635.975 -> There was one study that showed

2637.745 -> the aldosterone antagonists,

2639.23 -> so spironolactone and eplerenone may have some benefit

2642.41 -> but they're not going to gain

2644.075 -> FDA approval for diastolic heart failure yet.

2646.97 -> We end up doing things like

2648.29 -> controlling blood pressure,

2649.49 -> treating contributing factors,

2651.065 -> and then diuretics to keep the fluid off.

2655.715 -> There are new medications that are in

2657.26 -> clinical trials and hopefully,

2658.94 -> we'll sometime soon see

2660.635 -> beneficial medications for diastolic heart failure.

2664.385 -> You may hear about a couple of new medications.

2667.235 -> LCZ-696, as far as I know,

2669.68 -> it still doesn't have a name and it's not approved yet,

2671.84 -> but I already have patients asking about this.

2674.09 -> It combines an ACE inhibitor,

2676.43 -> so it's actually that medication

2677.66 -> enalapril we talked about

2679.07 -> with another hormonal blocker

2680.93 -> called a neprilysin inhibitor.

2682.895 -> It just targets yet another pathway.

2685.13 -> They did a big trial where they compared it to

2689.3 -> enalapril alone and found

2691.58 -> that it improved outcomes in systolic heart failure.

2694.22 -> The other medication that was just recently approved is

2697.97 -> called ivabradine and it

2700.04 -> slows the heart rate in patients,

2701.81 -> ideally who are already on Beta-blockers.

2704.775 -> That can improve outcomes in

2706.48 -> a select group of patients who

2707.71 -> still need more heart rate lowering.

2709.405 -> Last two things I want to talk about,

2711.115 -> implantable cardioverter-defibrillators.

2713.425 -> This looks like a pacemaker.

2715.24 -> It sits in the chest wall

2718.505 -> and it has wires that come to the heart.

2721.655 -> The idea is that patients with weak hearts, and again,

2724.655 -> this is systolic heart failure,

2726.395 -> they're at risk for

2727.745 -> ventricular tachycardia or other ventricular arrhythmias.

2731.165 -> Here you see the heart's beating

2732.47 -> nice and normally and then it goes into

2734.03 -> this wide fast rhythm that can be fatal.

2738.065 -> The ICD shocks the heart out of it.

2740.435 -> It detects that rhythm,

2741.47 -> delivers a shock,

2742.49 -> and it's quite effective for restoring a normal rhythm.

2746.09 -> We know that in patients with

2747.38 -> an ejection fraction less than 35%,

2749.54 -> it does save lives and improve survival.

2753.83 -> A couple of things to note.

2755.525 -> It's important that you are already on

2758.12 -> good medical therapy and reassess the ejection fraction.

2761.24 -> You want poor cardiac function

2763.43 -> despite aggressive medications.

2765.35 -> The other thing to know that

2766.94 -> I'm not sure patients always totally

2768.5 -> understand is that it has no effect on

2770.12 -> your symptoms or quality of life.

2771.815 -> It's just purely there in case you go into

2773.87 -> this rhythm to shock you out of it and keep you alive.

2776.99 -> But day to day,

2778.01 -> it's not going to make you feel any better.

2779.925 -> Then there's cardiac resynchronization therapy.

2782.695 -> This is also called biventricular pacemakers.

2785.215 -> In some patients, the heart usually squeezes in unison,

2790.6 -> so you have both ventricles

2792.415 -> just squeezing like that with every beat.

2794.685 -> In some patients, as the heart dilates,

2796.52 -> the heart stops doing that.

2797.75 -> So you might get the lateral part of the heart squeezing

2800.96 -> before the septum or what have you.

2804.62 -> What you end up with is this really wide pattern

2807.2 -> on the EKG tracing.

2809.675 -> A nice normal beat is pretty narrow signal like this.

2814.505 -> But some diseased hearts get these wider complexes.

2817.7 -> A cardiac resynchronization therapy

2821.525 -> puts one pacemaker lead in the right ventricle here,

2824.69 -> and then another one into something called the coronary

2826.76 -> sinus which effectively leads it to the left ventricle.

2829.505 -> You get pacemakers that can

2830.9 -> paste it the exact same time from

2832.565 -> opposite sides of the heart and really

2834.14 -> get the whole heart to squeeze together.

2836.03 -> It can improve symptoms,

2837.17 -> it can reduce hospitalizations,

2838.55 -> and improve quality of life.

2840.14 -> Often it's combined with the defibrillator,

2843.98 -> so you might have something

2846.2 -> that both does this resynchronization,

2848.54 -> but then also can shock the heart if

2849.83 -> it goes into a dangerous rhythm.

2851.585 -> This is just a chart I found

2853.91 -> from another heart failure presentation

2857.12 -> that basically outlines our approach.

2858.935 -> You start with diuretics to get rid of extra fluid.

2861.245 -> We always try to get people on an ACE inhibitor,

2863.285 -> then a Beta-blocker, then that aldosterone antagonist.

2866.3 -> If they're still symptomatic,

2867.83 -> meaning they're still limited in what they can do,

2869.93 -> we'll think about

2871.265 -> either cardiac resynchronization therapy,

2873.8 -> or if they don't have that widening,

2876.125 -> then we might still do an implantable defibrillator.

2878.51 -> If they're African-American, we'll think

2879.98 -> about hydralazine and nitrates.

2881.72 -> Then if there's still symptomatic with all that,

2883.505 -> digoxin is an option to just make people feel better,

2886.4 -> maybe keep them out of the hospital

2887.96 -> but does not prolong mortality.

2890.54 -> To summarize, it's always important to identify and

2892.88 -> treat underlying causes of heart failure.

2894.77 -> Successful management of heart failure

2896.33 -> starts with lifestyle modification.

2898.55 -> We have many medications to treat

2900.56 -> heart failure due to systolic dysfunction.

2902.93 -> Hopefully, soon we'll start to see medications to

2905.21 -> treat diastolic heart failure as well.

2907.28 -> Then devices such as

2909.11 -> implantable cardiac defibrillators or

2911.48 -> cardiac resynchronization therapy may be

2913.46 -> an option for certain groups of heart failure patients.

2915.86 -> Thank you. [APPLAUSE]

2921.7 -> Hi, everyone. I'm Liviu Klein,

2923.2 -> one of the other cardiologists in the group.

2925.87 -> I'm going to take you to the

2928.075 -> end-stage part of heart failure.

2930.415 -> As Dr. John Mohamed and Dr. Sylvia previously presented,

2935.42 -> you have different options for

2937.235 -> stage C or symptomatic heart failure.

2939.965 -> Sometimes despite all these

2941.36 -> good medications that we have,

2942.71 -> despite all these devices,

2944.39 -> the heart still progresses to get weaker and weaker,

2947.61 -> in which case, patients

2949.78 -> end up in end-stage heart failure.

2952 -> What is really the definition

2954.37 -> of end-stage or advanced heart failure?

2956.305 -> Well, somebody that has symptoms for

2958.36 -> a long time with minimal exertion,

2960.76 -> we call that class IV.

2962 -> If you remember the chart

2963.68 -> with the New York Heart Association.

2965.495 -> Really at rest or just walk into the bathroom,

2968.54 -> they get short of breath and they're really tired.

2971.765 -> Usually, these patients come to

2973.22 -> the hospital at least twice or three times a year.

2976.28 -> With fluid overload, they get diaries,

2978.71 -> they go home, and again they come back.

2981.14 -> Patients have been able to take medications,

2984.11 -> but now suddenly their blood pressure

2985.64 -> is too low or they have

2987.02 -> kidney failure because of poor pump functions.

2989.96 -> We have to stop the good medications

2991.76 -> that kept the heart working.

2993.635 -> These are all signs of advanced heart failure.

2996.65 -> Sometimes we need medications through

2999.5 -> IV to keep the patients out of the hospital.

3002.755 -> These are all bad science,

3004.57 -> meaning that the heart is failing.

3006.955 -> I just want to show a graph from one

3009.43 -> of the study that was done about 10 years ago

3011.17 -> looking at 100,000 patients that came to

3013.48 -> the hospital and they looked at

3015.1 -> how many times they were hospitalized.

3016.975 -> If you see here, in general,

3020.185 -> the patients that were hospitalized,

3022.96 -> about 60% actually were hospitalized multiple times.

3027.085 -> What they have here is survival.

3029.065 -> After hospitalizations for heart failure,

3032.905 -> how long did you live afterwards?

3035.02 -> If you've just been hospitalized once,

3038.05 -> the one-year mortality is about 50%,

3040.57 -> so still pretty high.

3042.07 -> But if you came to the hospital multiple times,

3044.5 -> your mortality was really high.

3046.81 -> People that were hospitalized more than three times,

3049.585 -> almost 80% of the patients were dead within a year.

3053.185 -> We don't really think about

3054.76 -> heart failure that is such a poor prognosis,

3058.3 -> especially in the end-stage.

3060.07 -> People are really worried about cancer.

3062.335 -> A lot of patients know

3064.24 -> that cancers have a relatively poor prognosis.

3067.165 -> But if you compare the absolute worst cancer

3069.67 -> that people can have,

3070.69 -> which is stage IV small cell lung cancer,

3073.48 -> the prognosis is really

3074.86 -> similar to end-stage heart failure.

3076.855 -> It is a very debilitating disease.

3080.425 -> We have about 80,000 people dying from

3083.2 -> heart failure every year from progressive heart failure.

3086.26 -> If you look at all the cardiovascular mortality,

3088.66 -> half of the people die from

3090.04 -> a heart attack or ventricular fibrillation,

3092.095 -> infections, and about 7-10% die from heart failure,

3095.74 -> again, about 80,000 or so in the United States.

3100.38 -> If you look at the overall US population,

3104.23 -> how many patients we're talking about

3105.955 -> affected by end-stage heart failure?

3107.905 -> We think we have

3109.27 -> about five million patients that have heart failure.

3112.495 -> As we've previously heard,

3114.76 -> they could be diastolic,

3115.96 -> so heart failure due to a very stiff heart,

3118.6 -> or systolic, heart failure due to a weak heart.

3121.99 -> In these patients, about a third are class I,

3125.245 -> so minimally symptomatic,

3126.7 -> about a third are class II,

3128.23 -> and a third are class II and IV.

3130.66 -> I think if we're pulling out

3131.89 -> all these subgroups of patients who probably have

3135.49 -> about 80,000 patients that are

3137.29 -> class IV and 80 years of age or younger,

3141.385 -> a lot of these patients die unless

3143.35 -> we have another therapy.

3145.84 -> Then obviously the best therapy

3149.14 -> we have for heart failure is a heart transplant.

3151.585 -> This is just a normal heart

3153.19 -> that one of our researchers took

3154.51 -> a picture before a transplant and this is what came out.

3158.215 -> We can appreciate the heart that the patient had.

3162.24 -> How much bigger is by three times

3164.34 -> bigger and thicker than the normal heart.

3167.4 -> Heart transplant is the treatment of choice for patients.

3171.595 -> Actually, survival after

3172.93 -> a heart transplant is excellent.

3174.475 -> The mean survival is about 14 years.

3177.115 -> We have a graph here from

3178.51 -> the International Society of

3179.68 -> Heart and Lung Transplantation looking

3181.39 -> at patients starting in 1981 when

3183.58 -> we started to do the first successful heart transplant.

3186.46 -> You can see over time the survival has improved.

3189.445 -> The most recent decade, again,

3191.77 -> the average survival is about 13 years

3194.05 -> and people get fairly normal quality of life.

3196.705 -> We're actually proud at UCSF to have

3198.58 -> a better survival than the national average.

3200.695 -> These are our data at one month,

3202.36 -> one year, and three years,

3203.755 -> and UCSF is here in the darker blue column.

3208.66 -> Again, we're better than the national average,

3210.16 -> so we're very proud of that.

3212.065 -> What do patients do after heart transplantation?

3215.485 -> Well, they actually go back to normal lives.

3218.545 -> The best story I'm telling patients,

3222.97 -> there's a famous surgeon in England called Magdi Yacoub,

3226.54 -> a very famous cardiac surgeon.

3228.55 -> He visited one of his patients

3230.455 -> before the transplantation.

3232.06 -> The patient asked her,

3233.28 -> "If I receive a transplant,

3234.39 -> can I go back to my regular job

3236.22 -> and do what I did before?"

3237.36 -> He's like, no problem.

3238.56 -> He never asked the patient what his job was.

3240.78 -> He's actually a soccer player,

3242.265 -> so he ended up going back and playing soccer for

3244.44 -> 10 years professionally in England after the transplant.

3247.425 -> If you look at the data again from the ISHLT,

3250.895 -> the red are patients that have no limitations.

3254.08 -> The majority of patients, actually 90%,

3256.675 -> had absolutely no limitations in terms of

3258.88 -> their regular physical activity

3260.74 -> after heart transplantation.

3262.255 -> It actually carried over even at five years.

3264.91 -> It's not just the short-term benefit,

3266.5 -> it's a long-term benefit.

3268.03 -> Probably about 10% have some limitation.

3270.845 -> Compared to some of those class IV,

3272.7 -> before they'd barely could walk the bathroom.

3274.68 -> Now, you have someone that's pretty normal again,

3276.87 -> so it's pretty remarkable.

3278.69 -> What about re-hospitalization?

3281.08 -> Well, initially after heart transplantation,

3283.27 -> the first year some people get hospitalized because of

3286.57 -> either infections or rejections

3288.34 -> or some other things related to surgery.

3290.41 -> But still the vast majority,

3291.7 -> about 50% do not get hospitalized.

3294.31 -> As they move forward from the transplant,

3296.59 -> things get much easier.

3297.82 -> Again, if you look at about five years,

3300.115 -> the vast majority are staying out of the hospital and

3303.13 -> just a very small number of

3304.63 -> patients come in for different reasons.

3308.06 -> You do have to take medications.

3310.95 -> A lot of the patients ask,

3312.33 -> well if I get a heart transplant,

3313.5 -> do I have to take medications?

3314.52 -> Yes. Unfortunately, you do.

3315.9 -> There are different medications,

3317.28 -> mainly try to fool the immune system to not

3319.86 -> reject the new heart.

3323.145 -> A lot of the immunosuppressive medications.

3325.795 -> There's different combinations of these medications

3328.31 -> depending on the case and the center,

3330.95 -> but everybody is at least on

3332.42 -> two or three immunosuppressive medications.

3335.51 -> Unfortunately, there's no free lunch.

3337.995 -> These medications do have side effects.

3340.5 -> Some of them can increase the blood pressure.

3343.425 -> Pretty much everyone will develop

3345.6 -> high blood pressure after heart transplantation,

3347.88 -> it's almost a given.

3349.53 -> Some patients develop kidney dysfunction because you can

3352.65 -> have a toxic effect of the medications,

3355.17 -> especially taken after five or ten years

3357.39 -> on the kidney function.

3358.92 -> Fortunately, very few patients end up on dialysis

3361.695 -> or needing a kidney transplant less than 5%.

3364.56 -> Majority have some kidney dysfunction which we

3366.57 -> can just manage with medications.

3368.955 -> A lot of patients develop high cholesterol.

3370.98 -> They haven't had prior, high cholesterol.

3373.485 -> About a third of the patients develop diabetes

3375.99 -> mainly due to the prednisone,

3378.69 -> the steroids that we use initially,

3380.25 -> and also some of

3381.75 -> the other medications that we use long-term.

3383.76 -> Again, usually, it's managed by diet and medications.

3388.215 -> Something that's very specific to

3390.06 -> the heart transplantation is called cardiac vasculopathy.

3393.465 -> It's essentially blockage that occurs in

3396.6 -> the blood vessels of the heart as

3398.13 -> a result of chronic rejection.

3400.23 -> If you remember prior to having

3402.21 -> heart failure, patients can get

3403.95 -> coronary artery disease where you have cholesterol

3406.02 -> blocking the arteries and causing heart attacks.

3408.375 -> This is a similar process.

3410.265 -> It's a different mechanism,

3411.6 -> but similar process where

3413.37 -> the blockage occurs in the vessels of the heart.

3416.31 -> About half of the patients

3417.78 -> after 5-10 years developed that.

3420.195 -> We become smarter and

3423.27 -> we have new medications to try to prevent that.

3425.565 -> We have new tests that we do after transplantation to

3428.835 -> foresee who will develop these type of

3430.71 -> blockage and try to prevent it.

3433.59 -> What is it to live with a heart transplantation?

3437.445 -> Well, it is an enterprise.

3440.1 -> People do have to change lifestyles,

3442.41 -> adjust their lifestyle to

3444.72 -> deal with all these other secondary issues

3447.18 -> that they have to take care of.

3448.785 -> They do require a blood test.

3450.6 -> Initially, it's three times a week,

3452.4 -> and then becomes weekly,

3453.42 -> every two weeks, every month,

3454.65 -> and then every few months.

3456.255 -> You have to make sure that you have

3458.97 -> a very rigorous infectious disease protocol

3463.56 -> because you're immunosuppressed.

3465.09 -> Patients are at risk for developing infections.

3467.43 -> You have to wear mask when you go in

3469.26 -> public or when you fly a plane.

3471.45 -> You have to really be careful about

3473.16 -> hygiene and then exposure to other things,

3477.48 -> and you have to take some antibiotics initially.

3480.105 -> As I mentioned, some patients do get diabetes.

3482.61 -> It's very important to control

3483.93 -> their diabetes so they

3485.73 -> don't develop complications on the long term.

3487.83 -> The same thing with the kidney function.

3489.45 -> Very important to monitor their kidney function.

3492.18 -> Patients are exposed to

3493.995 -> medications that can cause especially skin cancer.

3497.01 -> Dermatologists are usually becoming their best friend.

3499.5 -> They see them every six months to

3501.135 -> make sure that they do not develop skin cancer.

3503.475 -> Very important nutrition.

3504.9 -> A lot of patients are underweight before

3507.51 -> they go on their heart transplantation

3509.07 -> because they are very, very sick.

3510.24 -> They cannot eat. Once they get a transplant,

3512.94 -> their appetite comes back.

3514.545 -> The prednisone on top of that increases appetite.

3517.485 -> A lot of patients gain

3519.645 -> weight very rapidly, especially after transplantation.

3523.545 -> Unfortunately, then become lazy and then afterwards they

3526.17 -> keep their weight down instead of dropping it.

3529.335 -> Very important to keep their screening and

3531.72 -> health maintenance to prevent

3533.25 -> regular things that can happen.

3535.125 -> A lot of the patients suffer from

3538.08 -> depression coming in into

3539.43 -> transplant because they've been sick for so long.

3541.53 -> It's important to treat the depression afterwards and

3544.23 -> make sure that they are able to enjoy their life.

3547.215 -> Again, heart transplantation.

3548.73 -> It's seen as the best solution

3549.96 -> for heart failure patients.

3551.82 -> Unfortunately, there's just

3553.14 -> not enough hearts to go around.

3554.925 -> If we look over the last 20 years of

3556.92 -> how many heart transplants have been done in the world,

3559.86 -> we see about 4,000 or so.

3563.34 -> The green is the US so we're probably kept at about

3567.36 -> 2,200 adult heart transplants

3569.43 -> for the last 25 years or so.

3572.13 -> I remember, I just said at about

3574.935 -> 80,000 patients die every year from heart failure.

3577.95 -> Way, way underserved in that regard.

3580.92 -> Unfortunately, not a lot of patients are

3582.645 -> able to get heart transplantation.

3584.79 -> In fact, last year,

3587.745 -> we did about 2,100 heart transplants,

3590.625 -> and less than 25% were done in adults over age 65.

3594.915 -> If you remember what Dr. Mohamad showed in the beginning.

3597.705 -> The average age when people are

3599.48 -> diagnosed with heart failure it's 74.

3601.805 -> The vast majority of these patients

3603.62 -> are actually not candidates for

3604.82 -> heart transplantation because of the lack of organs.

3608.93 -> Fortunately, we have a new solution.

3611.48 -> In the last 15 years or so,

3613.37 -> we have ventricular assist devices

3615.53 -> or artificial heart pumps.

3617.42 -> These devices, you can just take them off the

3619.34 -> shelf and you can implant them in patients.

3621.715 -> I'll show you some data suggesting

3623.88 -> that perhaps this is the way to the future.

3626.505 -> We have these four types of devices,

3629.01 -> the first generation are pulsatile devices.

3631.725 -> They are done in about 2000 or so,

3634.44 -> so about 15 years ago.

3636.345 -> We moved over to the continuous axial flow,

3639.045 -> smaller devices.

3640.47 -> Then the third generation where we are right now.

3643.155 -> Then there's a total artificial heart

3644.94 -> for a very small subset of patients.

3647.01 -> The two main device that we use nowadays that are

3649.56 -> FDA-approved are HeartMate II and HVAD.

3652.92 -> I just want to show you a few diagrams.

3656.565 -> This is a scheme of

3658.785 -> one of the devices, first-generation device.

3661.47 -> You can see how big it is.

3662.7 -> It weighed about five pounds.

3664.395 -> It had to go into the abdomen

3666.99 -> and then connect it to the tubes to the heart.

3669.645 -> Then you have two valves and the pusher play that will

3673.5 -> get the blood moving through

3675 -> the pump and then back to the body.

3677.655 -> The second generation, the axial flow,

3679.92 -> it's actually much, much smaller.

3681.615 -> It still has to go in the abdomen,

3683.28 -> but weighs only about a pound or so.

3685.455 -> Vast improvement compared to the first generation.

3688.8 -> These are the actual pictures you can see

3691.26 -> the first-generation device and the second-generation.

3694.335 -> The pump, it's much, much smaller now.

3697.71 -> The second-generation pump we've

3700.5 -> been using for about 10 years.

3701.865 -> This was 15 years ago,

3703.17 -> this is 10 years or so.

3705.45 -> Now we're using the third-generation pumps,

3707.865 -> which are really, really small.

3709.695 -> These pumps are implanted straight into the heart.

3712.74 -> They don't need to go into the abdomen.

3714.57 -> The blood comes perpendicularly into

3716.73 -> the pump and then gets out from the pump.

3719.1 -> This is how small they are.

3720.57 -> They're literally you can hold

3721.71 -> them in the palm of your hand.

3722.82 -> They're really small.

3725.625 -> If you just look at the

3728.04 -> how the pumps are connected, again,

3730.5 -> the first generation pump was put in the abdomen,

3732.96 -> had big tube coming from the heart,

3735.09 -> and then a big tube go into

3736.32 -> the aorta to get the blood back into the body.

3739.02 -> Then you have a drive line,

3740.52 -> which is an electrical connector coming

3742.41 -> through the skin to a battery pack that

3744.36 -> the patients have to carry to power the pump.

3748.74 -> You had a pusher play. It was

3750.51 -> just pushing the blood around.

3751.845 -> They had air vents.

3753.06 -> They're very noisy. You could just

3754.29 -> hear it from the outside the room

3755.64 -> and somebody had one of these pumps [LAUGHTER].

3758.43 -> Again, it was a great development because

3760.65 -> until then the patients are waiting for transplant.

3763.59 -> They had to wait in the hospital for 3,

3765.45 -> 4, or 5 months tied in the ICU.

3767.46 -> But now for the first time,

3769.14 -> people could go home and wait for

3770.76 -> a heart transplant to become available at home.

3774.195 -> Unfortunately, very high infection rate

3777.06 -> because they are so big.

3778.485 -> Then usually after about 18 months,

3780.495 -> you have to replace them, so another surgery.

3783.12 -> I just wanted to show an X-ray to

3785.37 -> just visualize how big it is.

3787.815 -> This is one of my former patients

3789.63 -> from Chicago and I lived there.

3791.145 -> Here's a patient from Michigan who was 6’5”,

3793.5 -> and 350 pounds, so big guy.

3795.915 -> You can see the pump,

3797.43 -> it's almost as big as he is.

3799.395 -> There's no way this pump could go in women.

3802.17 -> In fact, no women actually were

3803.7 -> able to get this pump because it's so

3805.26 -> big or someone with a small body frame.

3810.35 -> Moving to a second generation, again,

3813.18 -> they're much smaller,

3814.53 -> maybe about 10 inches or so.

3817.185 -> They have mechanical bearings that spin

3820.65 -> the bladder around and push the blood through the pump.

3823.695 -> They're very durable. More than five years duration,

3826.68 -> five or six years.

3828 -> Again, then you probably had to do

3829.32 -> another surgery to change the pump.

3832.01 -> If you just look at the x-ray,

3835.575 -> you can see it's still in the abdomen but

3837.84 -> much smaller than the other pump.

3840.24 -> This patient is again one of my patients from Chicago.

3843.6 -> She was 19 years old.

3844.68 -> She had a postpartum cardiomyopathy,

3846.21 -> so she had a baby

3847.98 -> and then developed this heart failure afterwards.

3850.155 -> She weighed 105 pounds.

3852.165 -> You can imagine this pump going

3853.71 -> to someone who's 105 pounds.

3855.24 -> Much smaller, suddenly now became

3857.55 -> available to much larger patient population.

3861.29 -> Finally, see our jewel of the day,

3864.69 -> the third generation pumps.

3866.04 -> This is really how small they are.

3867.945 -> They get implanted into the heart

3869.73 -> directly and then you have a connector that

3871.44 -> goes into the big blood vessel of the heart.

3875.07 -> If you look at the X-ray,

3877.2 -> the size is the same size as the defibrillator.

3880.77 -> Really very, very small pumps.

3883.125 -> Very good use.

3884.625 -> Probably over 10 years,

3886.05 -> at least on the bench testing.

3888.105 -> They have 10 years of life.

3890.415 -> As everything else, there's complications.

3892.965 -> Again, there's no free lunch for this

3895.05 -> either, but they're manageable.

3897.42 -> Some of the complications, infections,

3899.49 -> especially with the driveline again,

3900.9 -> they all have these wire that

3902.01 -> comes out to connect the battery.

3903.72 -> Really patients have to be very

3905.16 -> carefully how they dress themselves

3906.87 -> and how they take care of that driveline bleeding.

3910.845 -> About 20% of the patients,

3912.69 -> especially if they had prior ulcers or

3915.795 -> colonic diverticulitis can bleed

3918.81 -> because all these pumps require blood thinners.

3921.625 -> There are metals, so to speak.

3925.815 -> Then if you don't get blood thinners, they clot.

3928.74 -> We have to put patients on blood thinners.

3930.48 -> Some patients can bleed.

3931.815 -> If you don't have a blood

3933.45 -> thinner or if your level is too low,

3935.1 -> patients can have a stroke.

3937.14 -> Fortunately, the device failure is very low.

3940.59 -> It's about 5% or even

3942.21 -> less where the pump actually breaks.

3944.305 -> These are man-made products so they can break,

3946.58 -> but fortunately, the breakage rate is very low.

3949.355 -> Then sometimes the right ventricle.

3951.695 -> Remember these are pounds from

3952.82 -> the left side of the heart,

3953.9 -> and sometimes the right is very dysfunctional.

3957.53 -> Then they do require

3958.895 -> either to put another pump on the right

3960.68 -> or doing a completely artificial heart.

3965.18 -> But they do improve quality of life.

3967.965 -> These are data from the clinical trial.

3970.38 -> I can see everybody was reading the beginning,

3972.63 -> so Class 4,

3973.8 -> and as they move forward over three and six months,

3976.29 -> everybody becomes green and blue so Class 2 and Class 1.

3979.935 -> Most of these patients become, again,

3982.515 -> pretty normal after 3-6 months and

3984.93 -> then go back to a normal quality of life.

3987.885 -> Also, their functional capacity improves markedly.

3991.125 -> This is a six-minute walk test.

3993.39 -> We ask patients to walk for

3994.98 -> six minutes and see how much they can walk.

3997.11 -> A baseline, everybody is around 200 meters,

3999.63 -> so it's about 600 feet.

4001.16 -> Then again, at about six months or so

4003.35 -> they double that distance.

4004.97 -> They do get stronger and able to exercise more.

4009.88 -> As I mentioned, this survival is pretty good.

4012.845 -> The overall survival is about 80 percent in one year.

4015.8 -> This is our own survival

4017.24 -> for patients who are a bridge to transplant.

4018.74 -> About 86 percent of the patients are alive or have

4021.89 -> been transplanted at UCSF.

4025.97 -> I think it's very interesting.

4027.875 -> We have a National Registry to look at

4031.85 -> these pumps and understand

4033.29 -> what complications and

4034.58 -> how many pumps have been implanted.

4036.305 -> You can see an explosion in

4037.94 -> the last five or seven years

4039.68 -> because these pumps are becoming better and better.

4042.59 -> In fact, if you look at last year,

4044.795 -> we've done more elevates and transplants because of

4048.5 -> transplants are such a scarce resource

4050.75 -> and Elba to just take them off the shelves.

4052.925 -> A lot of the patients even bridge to

4054.95 -> transplant now live three, four,

4057.05 -> five years on the pump waiting for a transplant,

4059.36 -> but having pretty normal quality of life.

4062.18 -> I think the future is bright.

4064.1 -> We have smaller and smaller LVADs.

4066.635 -> Then soon we'll head actually

4068.36 -> fully implantable LVADs where

4069.89 -> we don't have to have the connection

4071.48 -> outside the body and patients

4073.79 -> can really become fully independent.

4076.625 -> I think my personal prediction that

4078.785 -> in ten years we'll actually see a full implantable LVAD.

4082.1 -> There'll be miniaturized implanted

4084.35 -> with a small surgery and then we'll have

4086.63 -> probably at least ten years of life and then we'll have

4089.09 -> a cost that's actually affordable

4090.53 -> for majority of patients.

4093.34 -> Thank you for attention.

4095.45 -> [APPLAUSE] I'd like to invite one of our patients,

4100.34 -> Alex, who has gone through

4102.44 -> all the stages of heart failure.

4105.305 -> He actually has an LVAD.

4107.36 -> He can actually tell from his perspective how he

4111.23 -> feels and how he's doing with the LVAD.

4115.865 -> I had been experiencing problems for

4117.95 -> about four to five years with

4120.695 -> heart failure and being handled at

4123.26 -> a much reduced level of medication and things like that.

4126.665 -> Then it just became more and more pronounced where

4130.4 -> I had to seek more high-end care.

4135.28 -> In the end of 2012 or 2013,

4141.815 -> I was in at

4145.61 -> that Cal Pacific and they

4148.52 -> encouraged me to consider the LVAD as an alternative.

4152.33 -> When I finally did, they turned me down for it.

4154.22 -> They said that they didn't

4154.94 -> think my heart could take this,

4156.71 -> the surgery and basically told me to go home.

4159.77 -> Not the main doctor.

4162.26 -> But one of the doctors there said I'd be dead in a month.

4165.88 -> Then they turned me down for it.

4168.02 -> I went home, didn't die [LAUGHTER].

4171.23 -> It was a struggle every day sometimes.

4173.24 -> But I was still going to work. I was still going to

4175.01 -> the gym when I felt up to it.

4177.41 -> Then one of the doctors at Cal Pacific put me

4182.24 -> in touch with Dr. Klein and

4184.22 -> said they would consider taking a peek at me.

4186.89 -> I got accepted into the program for the LVAD with

4190.97 -> hopefully a transition that

4193.22 -> this would be a bridge to a heart transplant.

4195.92 -> I had the surgery done on October 20th.

4199.43 -> It was a rehabbing and

4202.52 -> the winner is tough because it's cold outside.

4205.04 -> You don't feel like being out.

4207.545 -> But I manage through that

4209.645 -> and I actually got back on track.

4212.27 -> I was at work all day in San Ramon where I work.

4214.895 -> I go to the gym almost every day.

4218.615 -> I'm probably doing more than

4220.475 -> Dr. Klein would probably would want [LAUGHTER].

4221.99 -> But overall, I've done pretty well.

4227.66 -> The folks here had been so nice.

4230.45 -> I mean, their LVAD team, the clinic people,

4234.32 -> everybody I've come in contact with,

4236.375 -> these fine doctors I've

4238.04 -> all had contact with and the surgeon.

4240.41 -> I can't say anything nicer about it.

4243.64 -> Initially you have the bag with you.

4247.31 -> It's like not a big deal anymore.

4249.89 -> I mean, most of the people that I

4251.18 -> come in contact with daily know what

4252.53 -> it is in my office and that thing.

4255.68 -> When I go to the gym, I

4258.08 -> wear very attractive fishing vest.

4260.255 -> It's got all these inside pockets

4262.43 -> so that you can tuck the batteries.

4264.71 -> You don't have the bags swinging around you.

4267.005 -> Then I put a hoodie over it or something.

4269.165 -> Everybody at the gym knows what it is.

4272.06 -> They're all real encouraging.

4273.755 -> I mean, do you know anything more to heart?

4276.83 -> I said, it doesn't work that way.

4278.705 -> They take your scheduling it for transplant.

4281.825 -> But in any event, I'm

4283.79 -> very encouraged by how I've been feeling.

4288.05 -> My life is probably pretty close back to normal almost.

4295.33 -> I took a couple of trips

4297.695 -> post-surgery but before I

4299.15 -> went on the transplant list because

4300.26 -> it's about a six-month wait till you can go in

4302.84 -> the transplant list because they

4304.31 -> have to recover from this surgery.

4306.41 -> I took one business trip.

4310.04 -> It went through TSA actually pretty well

4312.86 -> considering you're carrying batteries

4314.87 -> and wires and everything else through.

4316.49 -> [LAUGHTER] They could not have been nicer

4318.575 -> leaving Oakland and then leaving San Diego to come back.

4322.025 -> Couldn't have been nicer. They were so gentle.

4326.62 -> They couldn't have been nicer. I can't say enough.

4330.52 -> That's really what I've been

4332.96 -> doing You just have to be careful.

4335.825 -> I've not had any infection.

4337.325 -> I had great personal support.

4340.52 -> I'm not married. I had very close friends.

4344.51 -> I have a roommate, but I had

4346.19 -> a friend that came down from Utah who was with

4348.05 -> me because they have to

4349.73 -> become fairly educated in the wire.

4352.22 -> It goes on your side and you have to make sure that

4354.95 -> the bandaging is kept clean and everything else.

4359.705 -> He really stepped in and stepped up,

4362.195 -> and he's back in Utah now and he's just waiting for

4365.84 -> the call if and when

4367.685 -> the transplant becomes available. He'll be back down.

4370.34 -> As well so many of my friends and so many of my family.

4372.725 -> You have no modesty after all of this.

4374.99 -> [LAUGHTER] I mean, my female friends, my male friends,

4377.81 -> everybody see me naked in

4379.37 -> the worksheet for you now. You know what?

4382.055 -> I'm happy that everybody has kicked

4384.35 -> in from all parts of my life.

4387.035 -> But it's really been a good run for me.

4393.58 -> I don't feel weird. Like today

4396.83 -> I got a little bit of short of breath coming in,

4398.51 -> but it was because I come in from the East Bay

4400.19 -> and I was worried about being late and the bridge

4401.75 -> was bad and then I

4403.43 -> parked in the parking lot and sprint it over.

4405.11 -> Then when I got here and it was cold,

4406.34 -> I got out of the car.

4407.765 -> Then I got a little short of breath, but I'm fine.

4412.37 -> If I get home early enough, I might go to the gym,

4415.13 -> but I doubt it. But I do.

4417.77 -> I try to live a pretty normal life

4419.18 -> and I was fairly active before all this.

4421.115 -> That's my thing. [APPLAUSE]

4430.34 -> I think now we'll open up for questions from the audience

4432.41 -> for all four of us basically.

4434.6 ->

4436.43 -> It's a great question. Either an age cutoff

4438.77 -> for heart transplant or of integral since devices.

4441.845 -> Obviously for heart transplantation

4443.9 -> with limited resources,

4445.4 -> we don't have enough hearts.

4447.095 -> Different centers have different age cut-offs.

4449.6 -> Our centers cut off, it's 70 years.

4452.78 -> We are always say it's really how you look at 70.

4457.865 -> There's some young '70s and there are some old '50s.

4462.17 -> In general, 70.

4464.33 -> For LVADs we don't really have an age cutoff.

4467.69 -> We take it off the shelf.

4469.625 -> It really depends what shape patients are in.

4472.835 -> The oldest patient, there was implanted with LVAD was 86.

4477.44 -> It was done in San Diego and he's

4479.42 -> 92 now and he's still playing golf.

4482.15 -> It really depends how you feel and what shape you're in.

4487.34 -> The question is that if there's

4489.62 -> any correlation between sudden death and taking

4491.84 -> the blue pill sold NFL

4494.03 -> or Viagra or Cialis, is that what your question?

4497.795 -> There's no associated with between taking

4499.97 -> the pill and sudden death.

4501.86 -> There's association between

4503.12 -> sudden death and heart failure.

4504.41 -> But not with the pill and sudden death.

4509.41 -> It's a great question. The question is if

4512.33 -> the pumps are adaptable to physiologic changes.

4515.03 -> If you exercise, do they get better flow, more flow?

4519.335 -> The answer is yes.

4521.51 -> Remember the pump is

4524.255 -> designed to support the left side of the heart.

4526.955 -> The way the pump feels,

4528.65 -> it's from the right side.

4529.88 -> You'll still have your own

4531.14 -> right side of the heart that pumps

4532.55 -> the blood into the lungs and then back to the heart.

4535.835 -> Naturally when you exercise that,

4538.425 -> the heart is still ramps up,

4540.49 -> your flow that goes into the LVAD will be higher.

4545.485 -> The LVAD can actually

4547.12 -> increase the cardiac output when you

4548.5 -> exercise and decrease when you sleep.

4551.325 -> There are some variations,

4553.76 -> sometimes even up to one or two liters.

4556.37 -> The pump is designed to be able to pump

4558.47 -> ten liters of blood per minute.

4561.77 -> Great. The two questions,

4564.14 -> one is an average age for

4566.63 -> receiving the pump and then how is it reimbursed?

4570.335 -> I think the question about the pump,

4573.38 -> we have two types of patients.

4575.98 -> One is patients that we bridge to transplant.

4579.115 -> Obviously, those patients are younger.

4581.265 -> I would say average age,

4582.875 -> probably about 50, 55.

4584.81 -> Then we have older patients who are not

4587.195 -> transplant candidate because it could be 70 or 75.

4590.675 -> The average age for that group is probably

4592.43 -> around 70 to 73.

4594.605 -> In terms of reimbursement,

4596.405 -> they are reimbursed by private insurance and Medicare.

4600.605 -> They are reimbursed.

4603.44 -> The question is whether a thyroid disease

4606.875 -> has any correlation with heart failure.

4608.78 -> Both low thyroid and high thyroid

4611.33 -> can both cause type of heart failure as well too.

4614.57 -> The thyroid has a lot of roles in the body for

4618.32 -> different regulations in the body.

4621.545 -> If it's overactive or underactive,

4623.66 -> it can cause heart failure.

4625.565 -> Basically, if you supplement

4629.69 -> the thyroid or if you reduce the thyroid levels,

4633.425 -> that can actually improve the heart failure.

4635.675 -> Do you know the number of [inaudible]?

4638.81 -> We have a TSH.

4640.355 -> Usually, it depends on the reference lab

4642.23 -> or wherever lap you go to.

4643.34 -> But generally, five is a number.

4645.305 -> If it's below that,

4646.895 -> that means basically that the patient

4649.04 -> is hyperthyroid and vice versa.

4653.075 -> Hypertension is people focus

4657.14 -> mostly these days on the systolic blood pressure of 140,

4660.575 -> is the number we really like to see it below.

4663.11 -> When we're titrating medications,

4664.52 -> we usually like to bring it below 140.

4666.38 -> A real true normal blood pressure is more like below 120.

4670.94 -> People who have systolic pressures between 120

4673.91 -> and 140 are in that pre hypertensive range.

4678.155 -> There are some people who argue you should

4680.03 -> start treating that and targeting it

4681.86 -> much earlier on before

4683.03 -> people become actually hypertensive.

4686.09 -> Then what was the question about in terms

4687.38 -> of Beta-blockers?

4689.95 -> Yes because a lot of people have [inaudible]

4694.12 -> Beta-blockers, one of the medications we use for

4697.28 -> heart failure does slow the heart rate

4699.47 -> down and oftentimes a slow heart rate

4702.65 -> will be one of the limiting factors

4704.12 -> in terms of our ability to use it.

4705.935 -> We'd like to get the heart rate down to like

4707.81 -> the 60s or so but

4709.61 -> some patients will come in with heart rates in

4711.17 -> the 60s and when you put them on some beta-blocker,

4713.15 -> they dip down to the 50s or even

4715.64 -> lower and sometimes it'll become symptomatic from that,

4718.4 -> meaning they're lightheaded or

4720.02 -> fatigued or just feel terribly.

4722.675 -> Then that'll tell us, hey,

4724.55 -> there on too much beta-blocker,

4726.065 -> even though we'd love to have them on a high dose of it,

4728.69 -> they're just not going to tolerate it.

4731.41 -> The question is raised from skin cancer.

4734.27 -> I believe it was with heart transplantation.

4736.715 -> The medications that are used for

4738.92 -> transplantation can increase the risk of skin cancer

4742.205 -> and that's why patients need to go

4743.87 -> to a dermatologist usually every

4745.55 -> year unless they have

4746.72 -> a pre-existing skin condition

4748.1 -> then they go every six months.

4749.975 -> Correct. The medications actually can cause malignancies,

4752.87 -> solid tumor as well but by far,

4756.08 -> the skin cancer is the most common.

4758.19 -> The risk of, let's say breast cancer

4760.96 -> or colon cancer or lung cancer, it's fairly low.

4763.615 -> I would say maybe about 1% or

4765.43 -> so for each of these subtypes.

4768.625 -> The skin cancer is probably

4769.72 -> about 10-15%, so much, much higher.

4772.59 -> Early detection is always a double-edged sword.

4775.13 -> You don't want to over scan people or

4777.575 -> start treating things that won't

4779.18 -> actually become disease later on.

4782.56 -> I wouldn't want to say, everybody

4785 -> needs an echocardiogram.

4786.11 -> What I would say is that everybody

4787.49 -> needs what we call primary prevention of

4789.17 -> cardiovascular disease so it's

4790.91 -> really important that you get

4791.93 -> your blood pressure checked.

4793.145 -> It's important that you get your cholesterol checked.

4795.2 -> There are specific guidelines for all these about exactly

4797.72 -> how often you should depending

4798.98 -> on your age and risk factors.

4800.57 -> But controlling those kinds of things,

4802.745 -> like I was saying, sodium in

4804.35 -> the diet seems to be related to it.

4806.3 -> There are a lot of things we can do.

4808.265 -> Not smoking, not letting yourself get obese,

4810.83 -> treating sleep apnea, treating

4812.39 -> all the different risk factors

4813.59 -> which you should be doing anyway,

4814.85 -> because all those factors can lead to other things,

4818.135 -> will prevent a lot of cases

4819.92 -> before they become problematic.

4821.81 -> I don't think we're ready to advocate

4823.73 -> doing say an echocardiogram

4825.47 -> or checking that BNP lab or something in just everybody.

4830.075 -> I think there'll be a little bit overkill.

4833.33 -> The question is, it's ultrafiltration

4835.52 -> and the management of heart failure.

4837.395 -> Usually we try to relieve congestion.

4839.825 -> This is done in the hospital and we do that by

4842.795 -> IV diuretics or IV medication to

4845.09 -> help patients pee out the extra fluid.

4847.61 -> Sometimes patients don't respond

4849.41 -> and you can use a technique called ultrafiltration,

4852.68 -> which basically is actually removing the fluid,

4856.67 -> it's almost like a dialysis machine basically.

4859.715 -> We do use that if patients aren't

4861.5 -> responding to traditional diuretic.

4864.2 -> It's like one step short of, let's say dialysis.

4868.51 -> But most times you're able to

4870.62 -> manage with using diuretics.

4875.38 -> The question is how to reduce

4877.7 -> the 40% rate of infection and all that.

4880.535 -> Actually the 40% was the first-generation and all that,

4883.535 -> where they were really big and the cable that

4885.89 -> came out was like my thumb really thick.

4888.815 -> The current generation, the infection

4890.84 -> rate, it's around 10-15%.

4893.105 -> The cables that are coming out are really

4895.85 -> like a phone line.

4898.61 -> It's a really thin line,

4900.02 -> so much less chance of infection.

4902.735 -> Obviously very good hygiene when

4904.46 -> you change the dressing is very important.

4906.5 -> Avoiding trauma.

4907.76 -> A lot of patients drop

4909.5 -> their battery and then there's pulls on the skin.

4913.205 -> Then hopefully in the next five years will

4915.29 -> have fully implantable LVAD and that will

4917.24 -> completely eliminate the infection.

4919.745 -> It's a great question.

4921.275 -> What is the advantage of heart transplantation

4923.24 -> compared to LVAD?

4924.95 -> I think the main advantage is,

4927.8 -> we've been doing heart transplants for almost 30 years

4931.55 -> and we have a lot of experience and we have

4933.41 -> great survival to show.

4936.425 -> Our program here was started in

4938.72 -> 1989 and we still have patients transplant in

4941.21 -> since 1989 so the average survival

4943.7 -> is about 13, 14 years.

4946.265 -> We have been doing LVAD for,

4948.155 -> I would say less than a decade,

4949.55 -> especially these newer type of LVAD,

4951.41 -> so we don't have the data yet to say,

4953.45 -> yes with LVAD can survive

4955.31 -> ten years with no complications.

4957.35 -> We're getting there. I think right now,

4960.485 -> if you compare the two when we talk to patients,

4962.9 -> we can say with heart transplantation,

4965.09 -> we know for sure you will survive longer.

4967.355 -> But there may be a different discussion

4969.11 -> in five years where we can say,

4970.79 -> I think we will be able to say you have

4973.265 -> a similar survival and without that much medications.

4977.57 -> [inaudible].

4980.95 -> That's the hope and that's where

4982.43 -> the development in LVAD and becoming smaller and smaller.

4987.005 -> Again, there'll be great to just take something off

4989.54 -> the shelf and be able to implant it and say,

4992.24 -> I'll see you in 10 years.

4994.38 -> The question is, what's the rates

4997.75 -> of heart failure and men versus

4999.01 -> women and post-menopausal?

5000.75 -> It depends on the type of heart failure.

5003.405 -> We talked about the patients who have a stiff heart

5005.97 -> and then those who have a weak pumping heart.

5009.015 -> Patients who have a stiff heart

5010.65 -> or diastolic heart failure or have,

5012.555 -> however you want to call it, there's

5014.13 -> definitely an increased risk of

5015.15 -> having that in women compared to men.

5017.79 -> That's usually we see on the elder women as well too.

5021.515 -> Post-menopausal,

5023.47 -> there's not much of a correlation between the two.

5026.77 -> The question is the efficacy of

5028.99 -> coronary calcium scan for healthy adults

5031.06 -> that don't have any risk factors.

5034.885 -> I think it's very efficacious for people who own the

5037 -> scan no for the patients.

5040.59 -> Joke aside, the coronary cancer scan,

5043.6 -> it's actually useful tool when somebody

5045.49 -> has what we call intermediate risk factors.

5049.11 -> Much of what we do in medicine,

5051.97 -> it's based on statistics,

5053.59 -> so we have populations of people that

5055.51 -> we followed for 30, 40,

5057.43 -> 50 years and then we

5058.93 -> saw who did not have the heart attack or

5060.58 -> heart failure and probably

5062.56 -> everyone is familiar with the Framingham Heart Study,

5064.825 -> which is the longest study

5066.775 -> that follow people for development of heart disease.

5070.06 -> Based on the Framingham, we've learned

5071.8 -> a lot about what causes heart disease,

5074.02 -> high blood pressure, high cholesterol,

5075.79 -> diabetes, smoking, inactivity, obesity.

5079.045 -> If we put all those in equation,

5082.45 -> we can predict pretty much who will

5084.01 -> develop a heart attack, let's say.

5086.065 -> There are people that are very low risk,

5088.06 -> meaning that there's less than 5% chance

5091.3 -> over the next 10 years they'll develop a heart attack.

5093.925 -> People that are very high-risk,

5095.38 -> there is a 15% chance.

5097.195 -> Obviously, people that are very

5099.1 -> high-risk you're going to treat anyway so

5100.93 -> there's no need for an additional test.

5104.89 -> People that are low risk,

5106.3 -> you're not going to do anything different,

5107.68 -> just tell them to keep doing what they're

5109.54 -> doing and be it low-risk.

5111.79 -> There are people in between.

5113.635 -> Probably about 40% of the population is

5116.02 -> in-between so you have a choice saying, well,

5119.335 -> let's put you on some medication

5121.645 -> and then beyond the medication for the rest of your life,

5124.27 -> especially cholesterol lowering medication.

5126.43 -> They are plus and minuses,

5127.84 -> so they have side effects.

5129.265 -> Or you can say, well, let's do another test to see

5131.98 -> maybe you're not as much as a risk as we think you are.

5135.37 -> That's what the coronary calcium score,

5137.08 -> it's very useful in that intermediate risk population.

5140.44 -> If you do a calcium score

5142.48 -> and you have absolutely no calcium,

5144.28 -> that means you are at a very low

5145.48 -> risk and you do not have to

5146.56 -> start a cholesterol lowering medication for instance.

5148.93 -> If you have a high score, then you should

5150.835 -> start a cholesterol lowering medication.

5154.53 -> How I ended up this way.

5156.79 -> [LAUGHTER] Not smoking.

5161.545 -> I was fairly healthy,

5165.235 -> I'm HIV positive as well

5167.815 -> and I don't know if these doctors,

5170.05 -> but I had another cardiologist,

5171.61 -> telling me that the virus

5173.95 -> can get into the heart muscle and cause some problems.

5178.345 -> I don't know if you folks have found

5179.98 -> any correlation in that,

5181 -> but one of my other doctors had examined that.

5184.615 -> I was always fairly healthy but

5186.13 -> when it really started to come on,

5189.72 -> about a year-and-a-half, two years ago,

5191.74 -> I stopped going to the gym.

5192.76 -> I just wasn't quite up to it.

5194.56 -> I've really started going back after

5197.68 -> this situation and I think, I can't remember,

5201.88 -> I think it was Dr. Salvi,

5205.44 -> you were recommending the rehab?

5210.215 -> I have a friend who dragged me to the gym.

5214.275 -> By myself, I would have had the same thing.

5216.765 -> I was afraid to walk in the gym and pickup anything.

5219.45 -> I was afraid I was just going to keel over.

5221.79 -> But you get over that fear.

5224.015 -> I just don't have that anymore.

5226.15 -> I've gotten back into it, my muscle tones come back.

5229.705 -> I was like over 200 pounds,

5232.33 -> I was fairly into working out and everything else.

5235.15 -> I'm not a kid, I'm 63.

5237.595 -> But it's just,

5241.015 -> I think I had some congenital issues,

5243.34 -> I had irregular heart beats from a very young kid,

5247.96 -> pre-ventricular contraction was diagnosed

5250.69 -> when I was in my teens.

5252.505 -> I didn't really watch it until

5254.35 -> a few years ago and when it's

5255.655 -> about maybe eight or 10 years ago,

5257.17 -> when it started to become a problem.

5260.22 -> I'm back to it. Like I said,

5263.53 -> that's part of my life, so I've just gotten back into it.

5267.24 -> The question is that the immunosuppression drugs,

5270.31 -> why do they damage the kidneys? We actually know.

5273.49 -> One of the drugs that

5274.87 -> the patients have to take Prograf or tacrolimus

5278.275 -> produces vasoconstriction of the kidney arteries

5281.95 -> so they make the vessel smaller and because of that,

5285.52 -> they reduce the blood flow in the kidneys,

5287.395 -> they can cause high blood pressure and

5288.88 -> then eventually some kidney dysfunction.

5291.22 -> That's why we try to balance,

5293.5 -> we check the blood levels of this drug

5296.08 -> and then try to balance the level with the dysfunction.

5299.065 -> It's a very thin line.

5302.86 -> [APPLAUSE]

Source: https://www.youtube.com/watch?v=5PU4xExdEf0