Episode 2 - Success with Failure: Practical Perspectives for Heart Failure Management

Guests: Lindsay Castle, DO and Kenneth Varian, MD, PhD
Host: Kanny Grewal, MD, FACC, President, Ohio-ACC
Reference: ACC Guideline Hub for Heart Failure

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Transcript

Kanny 0:06

This is the cardio Ohio podcast, the presentation of the Ohio chapter of the American college of cardiology. This is canny gray wall president of the Ohio chapter and host for today's discussion. Further information about this podcast, including speaker biographies, as well as references are available@ohioacc.org. Where you can also provide feedback and suggestions for future topics. The podcast will also be available for download wherever you access podcasts, and we encourage you to subscribe, to receive updates on future sessions. And now for today's discussion. Welcome to episode two of the cardio Ohio podcast. Thank you for joining us today. Today, we're going to discuss some practical management tips for congestive heart failure. And I'm really happy to have two experts from here in Ohio to join in our discussion. First from Akron, Ohio, I'd like to welcome Dr. Ken variant. He's a heart failure specialist and clinical cardiologists with Suma. He's been involved in the Ohio chapter of ACC quite a bit. Ken, thank you for joining

Ken V 1:16

us. Thank you, Kenny. I'm really, really happy.

Kanny 1:21

And I'd also like to welcome Lindsay castle. She's a heart failure specialist here in Columbus, Ohio. In fact, she's here at Ohio health with me and she's been in practice here for two years, also a heart failure specialist and clinical cardiologist. Lindsay.

Lindsay 1:35

Welcome. Thank you. I'm looking forward to our discussion.

Kanny 1:41

So Ken and Lindsey, obviously all of us are clinical cardiologists. So we all understand, the immense burden of heart failure really, penetrating every subspecialty of cardiology and every aspect of our practice, whether it's the emergency room, whether it's the inpatient consult service or whether it's our outpatient clinics. And of course, most heart failure patients are managed by general cardiologists or other cardiac subspecialties. We also have an audience of advanced practice providers today and fellows and training. So quite a broad audience. We know the impact of heart failure is immense. Both in resources used overall costs to our healthcare systems. The first topic I wanted to ask you about is of course, in the guidelines, you know, most of our providers are very familiar now with several decades of evidence-base for the common medications, like ACE inhibitors and beta blockers, and diuretics. I'm sure you would agree that we often see many patients who are either on suboptimal doses of the guideline recommended medications, or maybe not on all of them for various reasons. Do you have any tips Ken for our day-to-day providers on how we can. Get patients to target doses. And do you have any personal tips on how you titrate the medications or implement them, for example, in a patient who's admitted with new systolic CHF in the hospital?

Ken V 3:06

Yeah. That's that's one of the things that that we focus on heavily every day. So I would start off by saying that for most patients. The goal is to get them on what we refer to now as quadruple therapy, which would be a beta blocker in RAs inhibitor preferably cubicle Valsartan and MRA, and an SGLT two inhibitor, the exact order and the speed of titration is, is very specific to a patient situation. So for example, most of the time I'll start with a beta blocker and one other medication, a beta blocker remains king in terms of its reduction. Death and arrhythmic, death, heart failure, hospitalization, everything. So we need to get the beta blocker on first. Usually I will usually try to get all four medications on before I really aggressively titrate, unless I'm dealing with a specific situation such as frequent PVCs or an SVT, then the beta blocker titration will take precedence. Or if I'm dealing with significant hypertension, then the security will Val start and titration may take precedence. If I'm dealing with someone with hypokalemia, the MRA is going to go on very early. If I'm dealing with a patient that has a CKD with proteinuria, or maybe has diabetes, the SGLT two is going to go on first. This is because the two is, are also used to treat those other conditions. The only thing I don't do is I don't add an SGLT two inhibitor and a renin angiotensin blocker on the same. And the reason is is that if the crediting rises significantly, I'm not really sure exactly which one was responsible. Cause both reduced GFR as a part of their mechanism of action. I'm interested to hear if Lindsay has. Some different methods that she uses in her practice.

Lindsay 4:46

Well, thank you, Ken. I actually have a very similar practice to what you just described. So I usually tend to start with very low doses of those four medications and we'll slowly titrate those medicines after I have at least three, if not four of the medications started. I think a couple of things I've noticed with my practice is for instance, if I have a patient with a relatively low blood pressure, I tend to use extended release Metoprolol instead of Carvedilol. If I have a patient with a very low blood pressure, I might start lisinopril at a very low dose and titrate up to about 10 milligrams before I try to switch to secu betrayal Valsartan as I, it sounds like in your clinical practice, you've noticed that that tends to lower blood pressure more than a very low dose of lisinopril. And I've had a very similar clinical experience. Even in my patients that are, that I'm following in the hospital that are very ill in the ICU, even in cardiogenic shock, I've found spironalactone to be relatively blood pressure neutral. And so I tend to add that on very early, again, even in patients that might be presenting with a cardiogenic shock, like state, I do try to titrate very slowly as I've found that that helps to limit side effects that patients might experience. And I try not to add more than one new medication at a time as if a patient develops a rash or has a serious side effect. And I've added a couple of medications. It's often difficult to tell exactly what medication caused that rash or serious side effects.

Kanny 6:35

So from both of your answers, it sounds like you would both consider sacubitril Valsartan as the optimal form of afterload reduction versus just an ACE or ARB. It sounds like you're both making an active effort to get really every patient with reduced DF on that agent versus one of the older agents. Is that correct? Lindsey?

Lindsay 6:57

yeah, that that is correct. My only hesitation has been for patients that have borderline blood pressure and also patients that have severe chronic kidney disease, especially those with a baseline creatinine above two. I tend to be more hesitant using that drug.

Kanny 7:16

Any other thoughts can

Ken V 7:17

Well, first of all I really agree with, with Lindsey's points, especially with regards to adding Metoprolol, assassinates when blood pressure is a little bit lower and the neutral effect of the MRA on blood pressure. I should note that Lindsay and I probably have a little bit of a different definition of low blood pressure compared to. Internal medicine physicians, or some, maybe even some general cardiologists. We see blood pressures in the high eighties and nineties and asymptomatic patients, and that is considered normal. So we aren't too scared about titrating medications when blood pressure is hanging out around a hundred and our fairly aggressive. To answer your question about secure patrol Valsartan I would say that I have the majority, but not a huge majority of my patients on sacubitril Valsartan with a reduced DF and mostly it's just because there are any number of reasons why you would choose. And medication like lisinopril or an ARB instead of secure patrol Valsartan one would be hypotension, as Lindsay said cost is another issue. And also it is a twice daily medication and some of our patients just do better on once daily, everything. And you can achieve that. You can achieve quadruple therapy while still doing once a day medications. And that can be important for some people.

Kanny 8:28

I know some, you know, some physicians I talked to ha still have a little bit of skepticism towards that age. And only because, there was really one main study done and the comparitor was an ally pro, but it sounds like you're both convinced that at least the evidence-base is there, that that's the preferred agent in terms of outcomes and risk reduction.

Ken V 8:46

Yeah, I think that the, paradigm HF trial was fairly definitive since then, however, there has been the paradise EMI trial life, as well as Paragon, which were not nearly as impressive as that's paradigm HF. I, I do think it is superior. I think that the data is not the strong. If you use the medication enough, you just get the sense that the patients feel better on the medication compared to what they were on before. I don't know how you feel about that.

Lindsay 9:13

Yes, I would totally agree with your prior statements. And certainly. The majority of patients that I've switched over from an ACE inhibitor or an ARB to sacubitril Valsartan feel better, their dyspnea is improved. They don't seem to have the fluid retention issues that they might've been having before that transition. I noticed when I'm following and terminal pro BNPs, that those are lower. So I would agree with you. evidence in the medical literature might not be the strongest. But anecdotally I think all of my heart failure patients are doing better on that drug when I have the blood pressure to use it. And the renal function remains stable. Yes.

Kanny 9:58

Great, great. I wanted to talk a little bit about diarrhetic specifically. I mean, obviously here, the goal is really symptom relief and relieving congestion. Most of us are very comfortable in the general cardiology world with, Ivy diarrhesis transitioning to oral agents, Of course, we did get a subset of patients that seem resistant to furosemide. Many of us, we'll switch an agent, an alternate agent to get a better response. Do you have any tips about which patients may do better with, with an alternate to, for us or might, or when you would consider someone a non-responder and try switching their diarrhetic agent Lindsey?

Lindsay 10:36

Sure. So that's an excellent question. So usually the maximum dose of that I would use would be around 80 milligrams bid. Personally, I have not found doses higher than that to be. That effective. But certainly the bioavailability for medications like torsemide for instance, is better than furosemide. So usually after I, I have a patient on 80 milligrams of furosemide twice a day, who is having issues with fluid retention. That is one of the triggers that I see to switch to a more potent diuretic In my practice, I tend to increase the loop diuretic to the maximum recommended dose, for instance, with torsemide to about a hundred milligrams twice a day, prior to adding Other diuretics, such as metolazone. I know in discussion with my heart failure colleagues, that some of my colleagues have a lower threshold to use metolazone. So for instance, if a patient is taking 60 milligrams of torsemide twice a day, and maybe calls in with a five pound weight gain and some heart failure symptoms, some of my partners, the tendency would be. To prescribe that patient either a two and a half milligram dose of metolazone or maybe a five milligram dose of metolazone and then get a weight or symptom update in 24 to 48 hours. However my practice has been to actually increase. Diuretic. So for that same patient, who's on torsemide 60 twice a day and has a little bit of weight gain. I probably would go to 80 of torsemide twice a day, or even a hundred twice a day for two to three days, and then get a weight, update, a symptom update from the patient.

Kanny 12:28

Can another situation we sometimes consider on the general cardiology consult services switching from. IV dosing of Lasix to a drip. And obviously, I know different clinicians have a different threshold to consider a continuous drip. Is there any advice you have to us general cardiologists about when, on the inpatient side, we might want to consider a drip or if ever

Ken V 12:51

this is, this is an area that of course is, has very little data. You know, we have the dose trial from 2011 that shed some light on this suggested. You know, a, a loop diarrhetic, drip was not better than, than bolus dosing. I would say that I tend to be a bolus dose or once I get it to 80 milligrams of IB Lasix twice a day. And at that point, if I feel like I have to go higher, I will usually put them on a drip of 10 or 20 milligrams per hour. And then I don't usually switch from the drip back to bolus dose. And you usually just turn off the drip and switch them to orals. as you know heart failure, patients tend to come back. And so oftentimes I'll put them on what I know worked in the past. And oftentimes that is a drip. I would say my, my threshold for a drip is lower, but it's mostly because, you know, days in the hospital equal complications. I know that putting them on a drip who can at times speed things up a little bit.

Kanny 13:45

I want to kind of turn our attention a little bit heart failure with preserved DF as well, since all of us who do inpatient consults know the burden of that condition, especially with the increase in so many of the comorbidities Ken, is there any new information for us about half pen that you can give our general cardiologists in terms of either management advice or any therapies coming down the pipe?

Ken V 14:09

Sure. So let me start off by giving you what I think the true definition of half puff should be. If we're talking about half PAF, we're talking about truly normal ejection fraction, so greater than 50%, the half trials, including Paragon, most recent ones. Anyway, Paragon HF, as well as emperor preserved. These both use. Ejection fractions of 45% and above or 40% and above respectively. And so there is a little bit of LV dysfunction patients contaminating these trials. So for example, in the Paragon trial, there was a hint that there may be benefit for secure vitreal Val Sargent in patients with sort of lower than normal ejection fractions. So the way I interpret that is, is that security level Sergeant is probably somewhat helpful over Val, sorry. In patients with still reduced, but mildly reduced ETFs, whereas it is not going to be beneficial over Vel Sartin for patients that have truly preserved ejection fractions. That's my take on that data in terms of new therapies. The, the biggest news was from last summer when, when emperor preserved, was resulted. And what it showed was that there was around a 30% reduction in heart failure, hospitalizations in heart failure with preserved ejection fraction patients who got empagliflozin 10 milligrams per day. And this was actually the first positive trial for heart failure with preserved ejection fraction patients for, for a pharmacotherapy. And there's a couple of footnotes to this. First of all, in. SGLT two trial. It doesn't matter whether you're, you're looking at diabetics with, corner disease, diabetics with cardiovascular risk factors chronic kidney disease, patients, proteinuria, heart failure with reduced ejection fraction patients. Every patient you give an SGLT two inhibitor, their risk of heart failure. Hospitalization will go down by about 30%. So what we found in this trial is that heart failure with preserved DF patients are no different. And there's something about the SGLT two inhibitor that really gets at the essence of congestion and preventing it with that said there's a couple of caveats, I would say to the true half PAF patient in, when it comes to prescribing an SGLT two inhibitor one is, is that if you look at the emperor preserve data, the patients did still came into the hospital. A very similar number of times. Between placebo and epic lifts. And there was about 2,500 hospitalizations in each arm, only 500 of which ish were actually heart failure with heart failure hospitalization. So while it did reduce heart failure hospitalizations, it did not reduce total hospitalizations. There were also no differences in mortality. So I think that when you go to prescribe an SGLT two inhibitor for a half PAF patient, what I usually do is I usually ask myself the first question. Does this patient's primary problem center around recurrent congestion. That's one and two. Do I have any other reasons to prescribe the medication? And most often you do, but if they're a type two diabetic, that's one reason do they have. Chronic kidney disease with proteinuria. That's another great reason to prescribe the medication. And so for that reason, I, I probably ended up putting about maybe a third to a half of my half pet patients on an SGLT two inhibitor and the other one's not going on because of other reasons, So that's my take on on half path in 2022, but I'm interested to hear what Lindsay's approach.

Lindsay 17:40

Sure. So I certainly agree with your use of SGLT two inhibitors. when I approach patients with Hef path, I kind of try to separate them into almost two categories. And so you and I both have certainly seen patients that have Hef pep because of an underlying infiltrative cardiomyopathy. And so I, when I see these patients, I always want to make sure that something like cardiac amyloid or another infiltrative. Disease process has not been missed. Occasionally I will pick up a new case of, of cardiac amyloid in a patient who's been labeled as having half pet for a number of years. Unfortunately, however, there's also the. puff population that you and I see that unfortunately is really struggling with obesity and poorly controlled hypertension, poorly controlled diabetes, untreated sleep apnea. And I, I really think that we have to talk to patients about. Weight loss and exercise and compliance with their treatment for sleep apnea. Certainly my patients who have been able to lose weight, they're the patients who are exercising more, have better blood glucose control. Those that are using their CPAP at night. I noticed anecdotally there they do better. They're not the patients that are in the hospital and really overall, they tend to feel better. And I think they have an improved quality of life.

Kanny 19:12

Thanks, Lindsay. I think you just encapsulated the entire cardiology consult service. Last time I was on service, but That's exactly right. I think we see so much of that. Co-morbidity and I think what I've noticed is our providers, our APS, we're much more sensitive about the relationship between, blood pressure control BMI. Screening for sleep apnea., which wasn't the case, five or 10 years ago. So can I just summarize both of your opinions by saying that it's basically time for a really every general cardiac provider to get comfortable initiating SGLT two inhibitors, and that should be part of our armamentarium. And would you both agree that you would consider that a cardiovascular medication at this point in time?

Ken V 19:53

Yes, definitely. It definitely is a cardiovascular medication. I you know, I don't think that, you know, every single heart failure patient should be on one for any number of reasons, but it is not a diabetes medication. It is definitely a cardiovascular medication for any number of reasons based on the fact that. Our patients or prevent worsening of our patient's chronic kidney disease based on the fact that it helps prevent congestion and based on the fact that they can reduce the risk of CV death, but to piggyback a little bit on what Lindsey said in, in half path you know, comorbidity management is, is really one of the key things with half puff. And even though we're, we are all excited about SGLT two inhibitors. There is no pill that can counteract the combination of co-morbidities that most of these patients have that you listed obesity, hypertension, sleep apnea, chronic kidney disease, diabetes, and there's no one pill that's going to reverse the decades of exposure to these co-morbidities that often these patients have.

Kanny 20:57

So, Lindsay, you kind of. Nicely transitioned into our next topic, which is the role of advanced imaging. You mentioned how, there's a subset of patients with have paths that you all consider screening for amyloid. So I wanted to just in our last 10 minutes or so, you know, address that. Obviously all of our providers were very comfortable using echo as the workhorse of imaging for heart failure. We understand its role for systolic function, diastolic function, assessing valve disease. But there's been a lot of advances in, advanced imaging and as an imaging specialist. You know, there's so much literature now supporting cardiac MRI for fine tuning. You know, the etiology of cardiomyopathy's looking for residual scar, looking for active inflammation. And of course we even have other imaging modalities. Pyrophosphate scanning now for amyloid screening that we're doing routinely clinically. So, Lindsay in, in your average patient or typical, I should say patient who's admitted was let's start with systolic CHF. We reduced the F when, when do you think about going beyond the bread and butter imaging of echo to consider either a cardiac MRI or screening for amyloid or other infiltrative disease?

Lindsay 22:07

So that's a great question. And I would certainly like to thank you and all of the other imaging cardiologists that are available to help us review these tests that we often order. So my approach has been. As far as ordering advanced imaging, if I'm meeting a patient in the hospital the first time or in the clinic, and they have a new diagnosis of acute heart failure with reduced EDF. And I don't have a good reason for that. So for instance the patient has always had well controlled blood pressure and we did an ischemic evaluation and the patient does not have obstructive coronary artery disease. if I'm not seeing something obvious when I first meet the patient then those are the patients that I do begin thinking about advanced imaging. I certainly order cardiac MRIs to look for infiltrative disease to look for fibrosis. And so usually a cardiac MRI is one of the first steps or one of the first advanced imaging studies that I would order in a patient that has an unexplained new, acute heart failure with reduced ejection fraction, as far as. Amyloid imaging is concerned. Usually I consider amyloid as a diagnosis in patients that have left ventricular hypertrophy. That's not well-explained in patients with other amyloid symptoms things like parasthesia. In patients that have had spinal stenosis in patients with history of bilateral carpal tunnel syndrome or in patients that have had tendon rupture again, that's, that's otherwise not. Well-explained now most of the algorithms for amyloid testing. Are actually very easy to find and review. They specifically focus on excluding a L amyloid first, and that is usually done by urine and Sarah. Immunofixation as well as light chain assay. So once a L amyloid has been excluded then usually I'm at a point where I would order the pyro phosphate imaging for TTR amyloid. Now sometimes type of amyloid is a little bit more difficult to distinguish. And so I certainly have found cardiac MRI to be very helpful in those patients to look for amyloid infiltration of the myocardium. Other things that make you think of, of amyloid of of course, would be a significant LVH on an echocardiogram with low voltage on an EKG.

Kanny 24:57

Yeah, I think we definitely with phosphate scanning kind of coming into the mainstream and being readily available, we've definitely seen an increase. And of course now with new therapy for amyloid as well, that's pretty exciting that we can intervene on that disease. It's definitely see that big interest in screening. Is your approach pretty similar to Ken in terms of when you consider MRI or other advanced imaging?

Ken V 25:18

Yeah, it is pretty similar. You know, I'll get a cardiac MRI on, on most non ischemics. If there are a little on the younger side, under the age of 60 or so I do it for a couple of different reasons. If I'm doing it towards the end of their initiation of medical therapy, I do it in part to get a more accurate ejection fraction. So for example, let's say I, I, I get a patient with a garden variety, non ischemic, or at least it appears that. And I've titrated their medications. And now it's three to six months later, I'll get a cardiac MRI to get an accurate ejection fraction, but also to determine the amount of late gadolinium enhancement they have in their cardio. This can really inform your conversation when it comes to a defibrillator, let's say the ejection fraction is still 35%, or maybe it's 35% up from 20, but they have no late gadolinium enhancement. You can be pretty confident that patient is on the lower end of risk of sudden cardiac death. And you can give them permission to delay the ICD longer. At least that's what that's, that's been been my practice as of late with the recent data on LG and, and the risk of sudden cardiac death. Obviously, you're going to, you're going to rule out or find the occasional cardiac sarcoid in that, in that mix as well. And we're also, you'll also find the patients that are loaded with LGE and you rush to get the ICD, you know, in a few weeks. So it can be helpful in that way. As far as the imaging for animals I don't know if this is what you've found to Lindsey is that the patients that I'm screening for this, they tend to be a little bit older. Listen co-morbidities and they almost always have abnormal capita Lambda ratios. And so it can become a little bit difficult to fully rely at all. And those folks, and so a cardiac MRI or a biopsy as is often needed, especially if the PYP is, is indeterminate. And the second thing I've noticed is that the heart to contralateral lung ratio that we obtained from a PYP scan can be misleading. And so for all of the patients that I order a PYP. I look closely at the SPECT images to see if there's uptake take directly in the heart and not just in the blood pool or other areas to make sure that I'm, that I'm dealing with the right that I'm, that I'm getting the right diagnosis with the PYP. Because I think the PYP, which used to have very good sensitivity and specificity, I think the specificity is reduced a little bit because of the wider range of patients that we're seeing.

Kanny 27:37

Yeah, that's very possible. And we do try to add SPECT imaging now to all our PYP is for that specific reason to make sure that the uptake is actually cardiac versus, rib or, or chest wall. I want to be sensitive to our time. We've only got about a few minutes left one very quick topic that I didn't prepare you guys for, but I just thought of when you mentioned ICDs is the wearable ICD and. This, I know it's been clinically available for several years. I know there's skeptics out there from the literature. I know supporters, but succinctly do you think there's a population that does benefit from the wearable ICD on their discharge for initial hospitalization? Or, or do we just need more information to clarify its ultimate

Ken V 28:17

role? Well, I I'd appreciate candy. If you can ask me a more controversial question. So well, I'll tell you what my practices, I'm kind of an in-between on the wearable ICD. I have colleagues that are absolutely against it based on the negative vest trial. And I have colleagues that put it on just about everybody with an EF less than 35%. That's leaving the hospital. It doesn't have an ICD. I offer it to patients who are post. With an F less than 35 almost universally, because I do think those patients risk of sudden cardiac death is high enough. And the only patients that don't go out with a wearable ICD are those that have decided they don't want it. I do not offer the. Device to anybody that is a little bit older with that is a non ischemic, because I'm not even sure that ICDs are helpful for those patients, unless they have a lot of non-sustained VT on their telemetry while they're in the hospital. So it's, it's a little bit of a mixed bag. I do have the conversation. But I also explained to them fully that this is not a proven therapy. I'm interested to hear what Lindsay has to say about that.

Lindsay 29:22

So my practice Ken has actually been very similar to yours as well. I tend to worry about the patients who have been in the hospital with a STEMI and have a low EMF at the time of that event. And I think. To be a little less concerned with older patients, especially non ischemics and definitely those with more of a chronic heart failure type syndrome. I think the one thing I've tried to keep in mind with this wearable device is that although we have not shown a strong clinical benefit in the medical literature, there has not been shown any harm. For the use of the device. And I usually include that in my discussion with patients as well. And of course, although we try to separate anecdote from the medical literature and from what we're doing on a daily basis I have had. Patients in my relatively short career to date that have received lifesaving shocks from the device. And so on. That's something that also plays a role in how I decide to use the device.

Kanny 30:32

So it sounds like with a positive literature, it's kind of a patient centered, a joint, a discussion that we should be offering our patients regarding the potential benefit and also the downside, Well, I thought of a lot more questions, unfortunately, but because of the time crunch I'm wondering if we may need to have a part two to our heart failure podcast at some point in the future, if both of you would be willing to join us. Is there anything else can, you'd like to add to our general cardiology audience before we finish up in terms of either potential new treatments or maybe advice on when a patient needs to see a advanced heart failure.

Ken V 31:07

So great question. So the, in terms of referral to an advanced heart failure provider, it's individualistic if you're a, cardiologist that doesn't treat a lot of heart failure, for example, if you're an electrophysiologist or if you focus only on intervention then the referral Threshold would be lower for other general, cardiologists will be much higher. I would say that any patient who, who you are down titrating medications because of blood pressure or having worsening symptoms, that you are unable to control with medical therapy, that is a person that you should be worried is heading towards advanced heart failure. And at that point, the patient should see an advanced heart failure cardiologist. Pretty quickly, because that is a person that may be going on to advanced heart failure therapies.

Kanny 31:51

Lindsay, any other final thoughts?

Lindsay 31:55

Sure. I know that our practice in particular sees a lot of patients that are referred after they've had multiple heart failure hospitalizations as well. So even patients with heart failure with preserved ejection fraction, who you're not really thinking, oh, this patient might need a heart transplant or might need an evaluation for a left ventricular assist device. I do think that there's a very important role for The use of heart disease at heart failure management programs and helping to keep patients with heart failure with preserved ejection fraction out of the hospital. And I know that that constitutes a large portion of our practice. Here at Ohio health, I would also just like to say That I look forward to continuing to collaborate with general cardiology colleagues and with primary care physicians. I think again, even in my short career, I feel like I'm seeing more and more heartfelt. Patients every time I'm on the inpatient service. And I think it's really going to take a large group of providers to care for these patients, not just heart failure providers specifically but certainly as we use SGLT two inhibitors more as we tie Tate diarrhetics to try to prevent heartfelt. Rehospitalization. And as we also tackle these diseases like obesity and diabetes and hypertension, I think it's going to take a number of both specialists as well as primary care to provide appropriate comprehensive care for these patients.

Kanny 33:30

Well, I think the pearls and advice both of you have given out during this podcast will, will be a great first step towards accomplishing that because certainly I've learned a lot myself and I'm sure our listeners have as well. We will be. Emphasizing heart failure as well. A future Ohio, ACC educational advance given all the new information and new agents coming out. So there'll certainly be more to come for all of our providers. In the meantime. I just want to thank you both for taking so much time today to chat with us about your knowledge and experience. And I definitely look forward to a future discussions with both of you. Thank you. Thank

Ken V 34:06

you. Let's do it again.

Lindsay 34:08

Thank you.

34:11

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