Daniel S. Yip, M.D., a cardiologist specializing in advanced heart failure and transplantation, presents on heart failure epidemiology in the Advanced Heart Failure Grand Rounds series.
maybe a little bit dated, but quite honestly, things haven't changed that much unfortunately. And we'll talk a little bit about all that. So we'll talk a little bit, at least on the, on the epidemiology part of the incidence prevalence outcomes, risk factors and, and what we can do to maybe modulator or some of the risk factors that come about. So talking a little bit about incidents, you know, really the incidents, we have about a million people who have a diagnosis of heart, new diagnosis of heart failure annually. That really hasn't changed that much. I really wanted to sort of emphasize a couple of things and that the incidents is highest in african american men and african american women and the lowest and um caucasian women and that has not changed very much over the years. Um, so are at risk population ship certainly is the african american population, uh, and there are other vulnerable populations, but that's where I think a lot of the, um, primary prevention, Secondary prevention is really important to try to stem the tide of heart failure. Um, if you look at your lifetime risk and every time I look at this slide, it really um, shocks me for, for lack of a, for many reasons. So if you look at, you know, if you're a 40 year old person, male or female or 40 year old person and and really no other history, your risk of developing heart failure sometimes in your lifetime is 20% which is Really remarkable to me. And of course all comers and some of these people will have influence. But if if, let's say you said, What's your lifetime risk for heart failure? You've not had my card function at 40 years old. If you're a man, you have a one in nine chance of developing heart failure. And if you're a woman, you have a one in six chance of developing heart failure. Sometimes during a lifetime if you've not had Myocardial function in your lifetime, starting at age 40, which to me is very, very striking. Um, and and sobering in many ways as to how um prevalent diagnosis of heart failure is. Again, you know, even though we live mainly in the world that systolic dysfunction, you have to remember that diastolic dysfunction and heart failure was preserved. Ejection fraction is a very large problem. Um, that in some ways it's actually more difficult to treat than people with heart failure was reduced, suggestion, faction. And later on in this series, we'll talk, we'll spend some time, well, there's a very nice talk that that's given about heart failure and preserved ejection fraction. And surprisingly how the outcomes, it's just as poor with those folks as it is and people are reduced. Yeah. So just, you know, to sort of wrap up the incidents things. So, uh, trends really haven't changed over tired. They're higher in men versus women, the incidents, um, they are more uh, instances higher in african american population, it does increase with age. It is hiring people with coronary partners. This which kind of makes a lot sense, right? Um, and again, even though, and if you break down the populations is highest in african american males, lowest in caucasian females. And if there's any time you guys have any questions, you know, just jump in. Um, it's free flowing prevalence. So the prevalence was about 6.5 million people who carry the diagnosis of heart failure. Um Uh and and it really hasn't, hasn't changed a whole lot over time, particularly in the 2000s, it's pretty, pretty steady, but again, about 6.5 people, 6.5 million people in the United States carry the diagnosis of heart failure. So let's move on to an outcome. So this is framing hand data and this little bit of data as well as um, the male Olmstead County data. And it really just shows what the fiber mortality is and it really hasn't. You'll see that has made some improvement over time. But you know, if you have carried a diagnosis of heart failure, you have a 50% chance of not surviving five years, which is again very sobering. Many, many of us have Patients who we followed for, you know, 10, 15, 20 years and they're doing fine. And, and so if that's, you know, those are the people that you're following, then think of all the other people who are not following, who are suffering with the significant mortality. There's also morbidity. So the gains that we've made is kind of small. If you guys run screens the gains we've made over the years. So this is 1950 all the way to 2000 have been early on. So, so not, you know, sort of in the first couple first, let's say six months or less. Uh they're diagnosed with heart failure. We've made significant improvements there. Um really resuscitated them early um early diagnosis um and intervening early on. But beyond that, the curves really are parallel over over the decades, really hasn't changed that much. Again. Most of our improvement has been over, you know, the early on, early years, but you know, we really haven't made very much improvement long term survival. And those of us in heart failure who, you know, it took a long time. It was early on that we saw successes from again, initially hard hydrology and nitrates. And then Jason holder has been shown to improve survival and the addition of beta blocker and the addition of Aldo Austrian blocker. And then there was a gap of many, many years where there was no significant improvement in survival in this length of time, right over a long period of time until very recently. So I mean, this tells you that we've not really uncovered sort of the secret beyond what we can do early on. Um So wanted to also put out from mortality standpoint and rehospitalization standpoint, the highest hazard for mortality and hospitalization. Or an african american males, they have a substantially higher risk than than um uh caucasian males and caucasians as a whole. Um and it's also the same case for re hospitalization. Um Speaking of hospitalizations, um you know, it kind of plateau doubt with a number of of, we have about a million hospital discharges um with a diagnosis of heart failure in a year. And the readmission rates still is sort of 20 to 25%. That really hasn't changed a lot, despite all the different processes that we have in place all the different time and effort that we placed, including um you know, penalizing hospitals for readmission that really has not been shown to improve our rehospitalization rate. So, you know, maybe I'll get off my soapbox unicycling, maybe that's not the right place to to incentivize our readmissions. Um So also want, it's another sobering factors is the overall mortality. So if you're hospitalized, The one year mortality is about 30% and that has not changed. So we still have a if you're hospitalized, if you If your heart failure was bad enough that you require hospitalization, there's a 30% chance from population standpoint that that you may not survive the year. Again, everyone's an individual, but, you know, it's sort of in group populations, a third of the people that almost a third of people don't survive a year after their index hospitalization for heart there, which is very sober. And and that's why, you know, when we talk about when to refer people, that these are, these are sort of our risk factors to say maybe we should think about referring these folks. So there's been a relative improvement over time. I would argue that this improvement has really been in the early stages, let's say, the first six months of diagnosis, but that is pretty parallel beyond that over time. Um, that there is a significant five year mortality of like half the people with a diagnosis of heart failure would not be alive at the end of five years, which is very sobering in my mind, mortality work increases with a worsens with age, which is no surprise and and is also very significant in an african american males. Um And really, we have not made any big changes in post hospitalization mortality over the years. Despite all the efforts that we have. So certainly anyone who is hospitalized for heart failure, we need to pay special attention to them because they are at risk for morbidity and mortality. Any questions on that so far? Mhm. Okay. Talk a little bit lower risk factors and we'll start that out with the case. Um Yeah, it is. Um A lot of these things, some of the things I want to talk about overlap a little bit with Prague's discussion last week, but the question will open up Which of the following two conditions represents the highest population. Attributable risk for developing heart failure. So which of the two conditions? So there's a diabetes and obesity is smoking and chronic skin disease. Is it hypertension? And coronary disease? Is a michael abdomen area and left ventricular hypertrophy? Or is there peripheral vascular disease and hypothyroidism. So, let you guys think about that and I'll give you some data to maybe help us answer that question. And this is a board question. Uh, you know, this is a question that is on the heart failure boards. It is a question that is on the cardiology boards. It is an important question, um, that even though, you know, the sexy stuff is new heart failure stuff, cardiogenic shock and that's kind of stuff that we always like to play in. But unfortunately, there's always these, these epidemiology questions that sneak on the boards that we have to answer and asked because it's a tried and true question. Right, It's just something that I would come. So let's talk about this. So there are a number of different risk factors. We all know that there's some um for heart development, heart failure and they're very similar development of the scheme of heart disease too. If you think about it, right, So age older you are, the higher the risk. Males tend to have a higher risk factor for heart failure for developing heart failure than than women hypertension. LDH certainly micro infarction, diabetes, value of heart disease, obesity. These are all the major risk factors, certainly Disl epidemiology, smoking, sleep disordered breathing, chronic kidney disease, anemia. These are other things that also contribute to the the development of heart failure and also the prognosis. So there have been, you know, over 100 heart failure associated risk factors have been described, identified. And and so like how do you sort them out? So Framingham looked at all the big things that sort of come to mind, the seven or eight big things that come to mind. And certainly from hazard ratio, hypertension and myocardial infarction are really way over with attributable risk and the double digits. And for hypertension in women, it's it's attributable risk of, You know, almost 60%. So certainly hypertension and coronary disease or micro fortune is uh, plays a significant role in the development of heart failure and it's been showing multiple times. Um, and this is in the elderly or systolic blood pressure greater than 160 and development in the presence of corners. These really increases the attributable risk for developing heart failure. And um, it also is present in the african american population, as well as the caucasian population. Perhaps even more so for hypertension, particularly in the corner disease. And the african american population. When compared to the caucasian population. Yeah. Um So the answer is hypertension and coronary disease that those are the two biggest risk factors that are attributable to the development of heart failure and anything we can do to reduce the incidents of hypertension currencies. And if there is development hypertension to um uh to mitigate the effect of the hypertension is going to help with decreasing the risk of developing heart. I will have to take to smoking. What's that? I would have picked smoking every time. It's just smoking. It's always a bad thing. But on a board question either there or eat Harmony, wherever it's just smoking always about. It's always a bad thing. That's got this marketing, it's good marketing. Then there's nobody marketing hypertension. You know, all the hypertension drugs, no one's pouring any money in a hypertensive because yeah they're they're they're they're doing it's all the new uh diabetes medicines. That's where people are spending all their money. We'll talk about that in a second. Um So risk factor risk modulation. So we talked a little bit about hypertension but we'll also talk about stage A. Right so A. C. C. H. A. S. H. A. Required recommendations. And remember stage A. Or people who are at risk for having built any any signs or symptoms of heart failure. So make sense. Right so we're all cardiologists at one time were all internist. So we should be doing these things or treating their hypertension according to guidelines. And again it's not only systolic hypertension but especially in the younger population. Diastolic hypertension is also a concern um treat their diabetes, treat their lipid disorder, encourage smoking cessation, encourage exercise, um mitigate the heavy alcohol use. And again, certainly there are populations if we have hypertension, use of ace inhibitor Air B could be beneficial for those at risk for heart failure. And perhaps people who have corners these use of beta blockers would also be very effective perhaps in reducing the risk of heart failure. So there is benefit in treating hypertension. Um So this is a meta analysis of a number of randomized trials that looked at the benefit of treatment hypertension. You can see that if you treat hypertension, your you have a substantial reduction in the incidence of heart failure as well as L. B. H. But you know, sort of More than 50% reduction in this meta analysis of development of heart failure for those who can treat their hypertension effectively. So there's a there's a plug for getting their blood pressure under control. But not all classes of drugs are the same. If you look at Gaza's oxen and cordial, don't they have a similar benefit from mortality? But if you look at just all cause mortality, but if you look at heart failure, the Caledon group did better than the docks jesus and that's all hat so that's not a specific heart failure trial. But it's kind of interesting that not all drugs are the same. Um 10 allow versus will start in um and this study showed that will start had a benefit of decreasing the incidence of heart failure. Um And so certainly that led to the recommendation earlier that if you think that you have a patient population at risk, perhaps using the ace inhibitor therapy would be beneficial, particularly the Atlas trial. Using uh rather proof has been shown that people are risk factors have been shown to improve their outcomes. So certainly consider an ace and A. R. B. Would be powerful. So again just this is all this is the A. N. C. Seven but it's really pretty much the same. So if you're concerned about heart failure using uh ace inhibitor and Air B. Perhaps a beta blocker diabetic therapy, Aldo astronaut antagonists would be compelling in this population of if you have hypertension. So if you're worried about heart failure and again um these other drugs are have its role but certainly if you have someone they're worried about heart failure again. So bring half the people the age of 40. Well that's our half 20% of the people with the at the age of 40 will develop heart failure sometime in their lifetime. So certainly leaning towards asian Arabic could be very helpful. Yeah. So here's the second question. So this is sort of heart failure, the elderly. So you see an 83 year old male has not seen a doctor in 30 years. So that happens not infrequently. And of course they come your clinic not because he wants to be because his daughter was probably from out of town. Said you know dad you really need to see the doctor. You haven't seen a doctor in a long time. He is very active. He's asymptomatic and his blood pressure on exam is 1 64 or 96 the rest of his exam is pretty unremarkable. The S. E. G. Is normal. Um The Kratt and maybe minimally elevated. Um And so assuming I guess for the boards you never treat the first blood pressure. Right? But let's say that the blood pressure has been persistent persistently. Listen to 19160s over 90s. What? Butch management regarding the management of blood pressure, which of the following statements is true. Um a there's no evidence of benefit with hypertension manager in the elderly greater than 80 years old. So treating the hypertension of no benefit in the elderly, That the systolic blood pressure up to 60 years old, up to 160 is normal in the elderly and the elderly. Northern. Uh And the elderly. Hypertension management does not does not reduce all cause mortality, but it does reduce fatal strokes and heart failure rates. And then in the elderly, hypertension management reduces all cause mortality, fiddle strokes and heart failure. Written race or the elderly, hypertension manager injustice all cause mortality, fatal stroke, race but not heart failure rates. So which one do you think? So? One of all? First of all, do you think it's important to treat hypertension in the elderly? Answer is yes, because we wouldn't be talking about this at the answer's no. And then, so, so then the question is in the elder, if you do treat hypertension, does it reduce all cause mortality, fatal strokes and heart failure risk or to some of these? And so we'll talk about that. Thanks. Oh, sorry. The answer is I'm sorry. I move the slide around. So the answer is it does improve all cause mortality fail, strokes and heart failure race. And this is the data here. So the data shows that this is in Patients greater than 80 years old, that those who are treated for hypertension have a reduction in fatal or nonfatal strokes. Um, all cause mortality uh, and mortality from cardiovascular causes, as well as death from stroke. So, as well as deaths from heart failure. So, again, treatment of hypertension and elderly is valuable and in all sides in all places and they are most effectively treated within this data used diuretics with or without ace inhibitors. So again another plug for ace inhibitors with the limited diuretic and frequently the elderly's hypertension is volume independent. So judicious use of diuretics sometimes are very effective in this population. So moving on from hypertension to dislike academia, certainly um the higher your blood sugar is or the development of the development of diabetes um increases your risk for developing heart failure over time. So again treatment of diabetes is effective and this is showing that the high your a. one c. is you have the higher your rate of development of heart failure. So again people with poor glycemic control um are increased for us for developing heart failure and with the new SGL T two inhibitors um showing improvement mortality. I think that's one of the one of our newer tools in our toolbox to see what can we do people with diabetes to try to improve their outcomes so um that there's more to be learned about the SGL T two inhibitors and perhaps one of the journal clubs coming up during the series, we can maybe spend a little bit of time talking about the S. G. L. T two inhibitors because it's relatively new. And not all the heart failure dots I think are very adept at using that because you know, we live in the heart failure world and even though at one time we were internist sometimes with all the new changes and diabetes sometimes are a little bit uncomfortable treating that. So metabolic syndrome certainly that goes hand in hand with diabetes. If you have metabolic syndrome, you're going to be increased risk for developing heart failure. Um obesity is a is a significant risk factor, is not as strong as hypertension and um coronary disease, but there is an increased incidence of development of heart failure. Um If you're obese and we're not gonna talk about this later. But there's a difference between risk factors of developing heart failure and risk factors for survival. So interestingly, uh there's a paradox if you're overweight, if you have the diagnosis heart failure and you're overweight, you're, your prognosis is actually better than if your weight was underweight. There's probably have to do with the cardiac agencia that's associated with advanced heart failure. So, again, we're talking about the risk factors for the development of heart failure. A little bit later on, we'll talk about risk factors for survival. Um But anyway, this is just I diverse a little bit, but certainly obesity places you at increased risk for the development hardware. So now we're going to talk about again, the risk factors and prognosis include a shift a little bit um from what there are risk factors that we associate with the development with heart failure. With, okay, you already have heart failure. What can we do with the risk factors that you have to modulate that or is there anything in the risk factors that you have that would perhaps give us an idea from a prognosis standpoint? So we're so that's kind of what we're gonna talk about. And touch a little bit about quality of life assessment or um um also known as um patients reported outcomes, which is another fancy word for quality election assessment. Um so again, it's really important if you have the diagnosis of heart failure many times people come to us and when they're in the office they say, well, you know, I know I have heart, someone told me I have heart failure, I've been referred here because they told me if I don't get a heart transplant and pick a time six months a year, two years, five years, whatever it is, you know, I'm going to die and so you know, I have a house payment, I have young kids, you know, we're thinking about moving out of town. You know, I need to know what my prognosis is. I mean I need to know, you know, am I going to be alive a year from now? Or do I need to start making plans or or am I gonna do I need to retire? You need to stop working. You know, I'm a I'm a physician. Do I need to, You know, I'm a physician, I'm 55 years old with heart failure. Do I say, you know what, I'm going to retire early because I only have five years to survive and I want to spend that time with my family or or do I do I do you guys think that I have you know 15, 20 years prognosis and maybe you know I can work a little bit longer from your family. So you know I think prognosis is really an important question and and sometimes we have really great tools and sometimes we don't have really good tools to help answer that question to get all the questions we answer for. The patient is based on population studies, right? In every individual is different. We can we can tell say somebody like if you have 100 people dislike you, you know Only 10 people, only 10 out of 100 really need a transplant. But are you one of the 10? Are you one of the 90 who don't need a transplant? So we really don't know very well other than population idea of where people are from prognosis standpoint. So there's lots of risk factors that are associated with outcomes have been described and I'm just going to go over a couple of them. Um So physical exam product talk a little bit about this last time is a powerful indicator from a prognosis standpoint. Again this is due mainly you know short term prognosis. So somebody who's got elevated juggle venous pressure or someone who has a third heart sound. Certainly their survival is going to be um not as good as someone who does not have related to blood pressure or presents with no S. Three. So again this is this is data that shows from a hospitalization survival death from all causes. Again the presence of a third heart sound because of J. V. P. Increases your risk for mortality. So again those signs are significant signs and I think if someone presents to you with increased pressure or third heart sound need to really pay attention to them because they are at increased risk. Um certainly ejection fraction is is significant. So if your ejection fraction is greater than 45% your prognosis is different than someone who's ejection fraction is less than 25%. So there are other tools that help us figure out the the differentiate those who are going to survive or not survive in these lower ejection fractions and we'll talk a little bit about that later on. Um But please note that most many of these deaths are son deaths that happen and that's why it's really important. That's why all of our data would show that if you eF is less than 35% you really need to have an I. C. D. Implanted for primary prevention sudden cardiac death. That if your class two and your EF is low you're more likely to die from an arrhythmia than you are to die from pump failure. So that's where that conversation. Sometimes it's difficult with patients that we have. Your EF is less than 35% and and maybe they have never been hospitalized for heart failure and they feel great. They are very active. They're playing basketball. If they are young enough to do that they're working. They're doing all sorts of things there. They have extreme workouts and you tell them hey you know what you really need to have a defibrillator implanted. It's that's a difficult discussion with them particularly if they're active particularly if they use their arms because you're talking about putting the defibrillator that impacts your lifestyle somewhat. But you're really doing them a favor because those are the folks that died from sudden death. Those are the people who come into some it happens time over time. Um So right ventricular dysfunction is also a significant risk factor for mortality. Um You know everyone that we see with the solid dysfunction and I don't really pay attention to the ejection fraction because everyone's got E. F. 20 25 at best, maybe 30%. Um And that's just the population that we deal with. What I really focus on is what's the right ventricle, like what's the right ventricle like? We'll also talk. I look at what and there's other things I look on the echo, but certainly the presence of right ventricular dysfunction is a risk factor for mortality and and certainly for symptoms symptoms as well too. So when I start seeing the right ventricular function starts to decrease over serial echo, I'm concerned. Um The second thing I look at on an echo, the left ventricle and diastolic diameter. In this one study showed that if you're left ventricular end, diastolic diameter is less than um 7.5 centimeters um then your prognosis is significantly lower than um than if it's um uh smaller. So I look at what's the size of the left ventricle and buy stock diameter. Is that increasing over time? Is that the same? The same as a decreasing to me? That's the other thing I look at on the echo. Um I don't spend as much time but other but but has been shown that people on the echo who have restrictive filling pattern have a decreased survival. I think that that is a sign of a sick heart when they started having a more restrictive filling than not. Um uh So that's the sort of, many people look at that as one of the eco findings um Left atrial size has been also used as a surrogate of looking for uh prognosis. Um And I'll just tell you what I do on the echo is I look at what's what's the left Tripoli and diastolic diameter. I look to see what the right ventricular function is like and I looked to see the severity of my tree vegetation. It's really impressive to see someone who's maybe has a dilated left ventricle but very little much regurgitation who really feels well. And for whatever reason when the left, when the when the micro irritation starts to get worse, they start to become more symptomatic. So those are the things I pay attention to. Pay attention to the left ventricle and diastolic diameter, right ventricular function and the severity of my tree vegetation. So I'll pause there. Does anyone what else does the group? Are there any other um factors or anything else on the echo that you guys sort of spend time on looking at? We're trending um Just valuable apathy. As you mentioned. I mean size of the ventricle, size of both ventricles functional both ventricles and then progression and TRM are especially after uh by these places. And that's not markedly improved that also information. But yeah it's also actually you know taking onto what process. It's very remarkable how if you are optimally treated someone medically with ace inhibitor beta blocker or uh or uh well or interest. Oh plus uh industrial blocker. How many of these factors to improve that? The M. R. Gets better. The RV becomes smaller. The left ventricle in diastolic diameter starts to decrease in size, particularly with the beta blockers. It is quite remarkable um how much improvement, you'll see what time I'll spend a little bit of time with functional capacity. You know the certainly in your heart association classification all of us know this um by heart um It does play a role in prognosis. We know that uh this is solved data but regardless of whether you received data, block, whatever trial ace inhibitor or didn't receive inhibitor, there is a significant difference in mortality if your class four versus class one. So the more severe symptoms are the more your worst prognosis citizen. Certainly people move from one class to the other but certainly people persistently Class three. Class four we're going to have a higher mortality and people who let's say we're class three at one time but we will get them to class one or two. Um This is a really busy um slide really. What I wanted to say is let's say if you just do a simple six minute walk, do a six minute simple six minute walk and you're able to get more than 4.5 m 450 m. So if you do a six minute walk and they can accomplish or they can travel more than 450 m in the six minutes, their prognosis is very good. These are the people they don't need transplants, they don't need advanced heart failure therapies. They just need good um evidence based therapies and and doing a six minute walk annually if you don't have access to a cardiopulmonary exercise study is a very valuable tool in trying to assess what prognosis is. Um When when I see somebody for the first time I do try to get an idea of what their functional capacity is. And can they vacuum? Um Do they can they make the bed without stopping because they put the dishes away? Um Could they put things above their head? Things like that. Simple things like that certainly sometimes will give you an idea what the functional capacity is. Um uh Probably going to say something. Yeah I completely agree. I can't I can't tell you how many times we you see somebody the clinic and they you know the the patient themselves says oh yeah I exercise X. Y. And Z. And I can do X. Y. And Z. And then you put them either on a six minute walk test or cargo bombing stress test and they vomit or they don't do well. And so I think um you know I think doing a six minute walk test gives you an idea as to um Number one with their functional status is number two whether you can trust what they're saying um in clinic and and it may kind of give you a you know a year to year kind of delta may give you an idea as to whether somebody is declining. Um And so I think it's a very useful tool. Sorry for interrupting their yeah. Um but you know for us in an advanced heart failure and transplant we use the video to stress test and a little bit of talk later on in the series about all about that. For those if you are aware we use a cut point, it's an old cup point of 14 mm per kilogram per minute as a prognosis. And this is sort of the inflection point. Um Or if you're 14 13 14 million per kilogram per minute or less. Your prognosis is poor compared to if it's greater than 14 million per kilogram per minute. Um, but beta blockers, the data that Donna Maccioni's data from the use of $14 per kilogram per minute or the more recent. I mean, and after that people use 50% predicted as a cut point for mortality. Um, people with beta blockers that those are, that was those studies were done in the pre beta blocker era, or beta blockers are not used very much. Certainly we know that the people, the standard of care right now, as people with decreased left ventricular systolic function should be receiving beta blockers. We also know that beta blockers decreases oxygen consumption because by decreasing heart rate. So maybe that 14 mL per kilogram per minute is not the same as someone who is on a beta blocker. So it turns out that if you are on a beta blocker, maybe it's not 14 mL per kilogram per minute, that's your cut point. It may be less than that. So again, uh so we all sort of mix that up with. Uh So maybe maybe someone with a vo two max of 12 or 13 million per kilogram per minute is okay if you're on a beta blocker, but if you're not on a beta blocker, maybe 14 is a better can point. So there are a number of studies that sort of try to try to talk about that human dynamics not gonna spend a lot of times other than certainly from a cause mortality. Doing the human dynamics again, might regurgitation plays a significant role in predicting uh survival. Um So the presence of might regurgitation, a low credit index um and a high mean pulmonary pressure, all risk factors for the development of uh prognosis for survival. Um Again, this is not only based on cardiac output but what's your critic output in response to exercise? So people who who are able to increase their um who have a normal part of our normal cardiac output response to exercise, their survival significantly better than people who have not been able to increase their odds cardiac output in response to exercise. Um Not gonna spend a lot of time of biomarkers, but certainly we know the higher your BNP level, the higher your north different level. That's a sign of poor prognosis. Um Well, what we what you may not realize is is uric acid level is also high. Uric acid is also a risk factor from a prognosis standpoint. It's probably a surrogate or is a surrogate for reduced renal function. So certainly that goes hand and hand. Um And certainly low sodium is um Pride is a poor prognostic factor when looking at mortality. Um hemoglobin. Also, anemia has been shown to the presence of anemia has been shown to uh pretend higher mortality. However, like many of the other things treatment of anemia has not been shown to reverse that mortality risk. But certainly someone who comes with anemic you really are concerned because there are higher risk and probably are the ones that you're more concerned about rather than people who come seeing you with a normal human clothing. Um talked about real dysfunction. Certainly people with elevated created are increased risk for our hospitality and heart failure. Death, but not our creations are the same. Um These are different examples when someone has a democrat and at one point to what it means um Certainly a G. F. R. Is a better reflection of what the renal function is like. Um And so the lower the G. F. Are the worst of prognosis. So if you're G F. R. Is less than 45% of less than 45 than your prognosis is much poorer than people who have better on G. F. R. So anybody with chronic kidney disease, stage three is would I wouldn't mind my would be considered increased risk and that's pretty much our whole population and the male heart flutter program. Unfortunately from electrophysiology standpoint, we all know this. The wider your cure. S is the higher your mortality. And that's why people with the QRS duration greater than 1 50. We recommend that they uh re synchronization therapy be considered because that's been shown to improve mortality. Um In the last couple of minutes we'll talk a little bit about uh patient reported some some about patient reported outcomes, but also some of these other heart failure scores product touched on that a little bit earlier. So um The question is there's a 60 56 year old male with history of antimicrobial function, severe left ventricular dysfunction. That's referred to you for consideration for transplantation. Um So with respect to the prognosis determination which of the following is true. Um Shh FM. Is the Seattle heart failure model incorporates the use of medical therapy and can be used to Lisk. Well can be used to list patients for transplant. Um Be peak Vo two provides the same prognostic information as a heart failure survival score. HFS. S. Is heartfelt society score. H. F. S. S. But not S. H. F. M. Includes the K. C. C. Q. So this is sort of. Uh huh. Ah. Uh huh. Number of abbreviations. So just remember Casey CQ. Is a Kansas city cardiomyopathy questionnaire score S. H. F. And there's society heart failure models developed for outcomes among hospitalized heart failure patients. HFS. S. Is heart failure. Heart failure um Survival score was developed in patients with advanced heart failure to a listing decision but does not include the impact of medical therapy. So I don't think that there is uh this is sort of esoteric, I don't think it's really that important. Other didn't understand what are the factors that go into these different scoring models so that you know Prague yesterday last week has said you know who uses these scoring models and we don't use them very often but we do have in our minds what our components to the scoring models um and what are important and we have that discussion with our patients regarding survive. So it turns out let's look at the heartfelt survival score. So it is um it looks like a number of different variables. The ones that came out were ischemic heart disease, left ventricular ejection fraction, mean blood pressure, peak vo two um Y QRS serum sodium resting heart rate. So these are all the seven variables that go into the survival score again. Does it matter what the score is? Yes, it matters because we do know that people with um lows risk have improved survival. But I would say that the biggest takeaway are these are the things that if you're patient has, you have to be pay attention to it. They have ischemic heart disease. If the EF is low, if the VO two is low, if their blood pressure is low there, Y QRS complexes, they're serious, sodium is low and they have an increased heart rate. You know that these people are increased risk and you pay attention to those folks. You don't have to know the actual score. But you know that people who have these are increased risk. Um But it does not take into fact treatment, right. It does not go. It just says, do you have these risk factors? What's your prognosis doesn't talk about, you know, what medications you are and things like that. But the Seattle heart failure model does include medications. So, if you're using this tool, it does include blab data. So, here's what you're asking here. Right? So that's that's part of the the the Seattle heart failure model looks to see what drugs you're on, what medications you're on and is there improvement in survival if you check these different um um um medication treatments also are using a device. So, those are all criteria that news. Again, this does take in the fact that data does take into effect uh into uh into consideration what medications, but it does not take into include into Account what they're vo to stress test results is or six minute walk or anything like that. The one thing about just remember in the Seattle heart failure model is that these are outpatients um that were used to do the model um that it's not for inpatient patients who are impatient. And the data would suggest that it underestimates the risks. That means to overestimate survival again, because these are all outpatient folks, not patients who are in the hospital. So if you're looking at that, it maybe it's a good starting point. I think this product has used it uses in his practice where if you check off, you know that this is the benefit. If you take your agent here, this is a benefit if you take your beta blocker. So I think there's value in that. But I think to actually use the numbers, I would be a little bit cautious because everyone's individual and maybe a little bit different and we do know that it probably underestimates um the risk. So that means overestimates survive. So the answer to this question was the heart players um the heart failure uh survival score was developing heart failure. That's heart failure patients but does not include medical therapy. Remember this is seven risk factors associated with heart failure develops. So just a little bit about quality of life assessment in the last couple of minutes. So those are the patient reported outcomes. Um and so it's important to get the patient's perspective. I mean, you know, what can you do, how much, how much fatigue and distant do you have? You know, and certainly that plays a role in their psycho, social interactions with others and with complying with medications and sometimes there's a disparity between um what patients report, how they're feeling, what they tell you and and really how they really are. And sometimes these different models are these different surveys are very effective in in sort of getting at the truth and the patient reported outcomes. Um So uh this is sort of the alphabet soup of of of K. C. C. Q. So Kansas City cardiomyopathy questionnaire uh in the M. L. W. H. F. Is the Minnesota living with heart failure score. So these are two different tools there that are used many many times. And you see that many papers there's a difference between the Kansas City cardiomyopathy questionnaire versus the Minnesota living with heart failure. There. In both cases they are patient reported outcomes for the patient will let you know how they're feeling. Um And there's a kind of a silly question which one it is. We'll talk about that in a second. Um but uh this is the Minnesota living with heart failure score. Um it is 23 questions, 22 or 23 questions is in the twenties, it is the um the higher your score is, the lower the score is um the worse it is. Um so it's the opposite as a Kansas city question there, whereas um uh the higher the score is the better you are, So it's the actual opposite. That's why the question is the lower the Minnesota score is, the better the outcomes. Um and so that's just for, so you want to see a low score for the Minnesota living apart. You want to see a high score for the Kansas city question there if you want to look at that and I guarantee you if you're taking the heart failure boards, this question will be on here because one, nobody really cares. And two, it's an easy question to ask. It's been validated, but I say that in jest, but there is value to this because this is the way that you can really get at how people are really feeling. And there is the validity and that if there is improvement in the Kansas city, um, uh, cardiomyopathy questionnaire or improvement in the Minnesota living with heart failure score that show there is actual improvement in survival. Um, and on our heart and our bad patients, we do that routinely. Um, and, and I would and I would suggest in probably selected populations, there may be value in measuring that, um, on an ongoing basis just to see where things are. And so if you were to just look at your patients and say, what do we want to do to show you that? Let me give you that. So you can write that down. So you say, well, so what what do I what can we do to follow our patients on a regular basis um and not spend a lot of money to see how they're doing. And I would suggest doing a six minute walk on a regular basis and doing one of the patient reported outcomes. Um um surveys like either the Kansas city or the Minnesota living with heart failure. Um The question is if you did that on a regular basis, um especially if you're a really busy practice, you may be able to sort of follow house how people are doing without spending a lot of money. Right. I mean your staff can you can someone staff can administer the survey And give you the results. Someone can do the six minute walk and give you the results. I think there's value in getting an echo periodically. I know that goes against the the the use criteria. Um But I think if if you feel that there's perhaps been a change in patient's uh condition is it's worthwhile doing eco we always get an echo once been optimized medically. Um When we think that we have them on the optimal medical therapy with beta blockers or an army or Racing Hibbert AARP or Aldo Stallone blocker. Um and we've had the chance for them to exercise and maybe get through cardiac rehab. To me, that's the optimal time to get the echo and we do in our practice will do a cardiopulmonary exercise at the same time. And your practice, if you don't have that available to you doing a six minute walk at that time would be I think that's the most valuable time to do those things. So I'll stop there
