How NOT to Fail with Heart Failure

Transcript generated by AI.

Welcome to the MedEvidence podcast. This episode is a rebroadcast from 
a live MedEvidence presentation.
So what we like to say when we do these talks is that there's no such thing as a free lunch. So you guys are enjoying, hopefully, the food that's being served, but we're going to make you work for a little bit for it. We're going to cover these areas here, and that's going to be the job of my fellow rock stars. 
But you guys have a job as well. So your job is to answer these very important questions. 
So we're going to figure out how smart this audience is and we're going to give you some quiz questions.
So question number one: W hat is heart failure? 
A condition in which the heart cannot pump blood effectively to meet the body's needs. 
A condition for which at least five classes of drugs have clinical trial-proven benefits. 
A condition that leads to many hospitalizations and rehospitalizations. 
A condition for which cardiologists make money.
Or all of the above. 
Oh my God, you guys are so smart. All the above is correct. 
So we're going to cover all these things. We're going to talk about the economics of it, the medical elements of it, and the treatment elements of it. 
So at the end of the day, you'll have a pretty good knowledge of all these things. 
So to jump in, we're going to give Doctor Henriquez the first educational spot. 
He's going to talk to us about the epidemiology of heart failure. 
But first, a quiz. Rank in the order from least to most frequent reason for US hospital admissions. 
Who here plays trivia?
A group of them. 
So one of the things that they like to do at trivia contests is give you a bunch of things that are hard to discern and ask you to put them in rank order. 
So they'll say, like from east to west, how do these towns line up? 
And they'll be really, really tricky to know. 
So in light of that concept, we want to create this question. 
Rank in the order from least to most frequent reason for us hospital admissions. 
One, sepsis, two, heart failure three, paroxysmal nocturnal hemoglobinuria or four, childbirth. 
Okay, so let's make it; we'll start with the easy one. 
Which is the least frequent?
Does anybody think it's not three? 
Okay, well, there you go.
So if you don't know what it is, chances are it's the right answer as least frequent.
And I'll tell you a funny story about it. 
But the answer is in fact three.
And all the others are about equal. 
So paroxysmal nocturnal hemoglobinuria is actually a little internal joke with myself, because when I was in medical school, when we were learning about a condition that we would never see in our lives, we used to talk about paroxysmal nocturnal hemoglobinuria. 
I'd never actually seen a case of it, but it's something that we studied extensively, and I can tell you about it, but has never done me any good because I've never seen a case. 
And have you seen a case of that?
I don't think I have. 
Okay.
Have you seen a case of it? 
So it's a great example of something that's out there that they like to teach in medical school, but that we don't never see a case of it.
The flip side is all these other things we see every single day, not only do you see them every single day, but at any given time, we're going to have patients in the hospital that have these problems. 
So these are the things that we deal with on a very consistent basis. 
And heart failure admissions are nearly as prevalent as childbirth admissions in the United States.
So it's a big, big problem that we're going to dive into.
Okay, so now we're going to have Doctor 
Henriquez talk to us about heart failure statistics. 
Thank you for having me, Mike.
Thank you all for being here today. 
Heart failure is one of my greatest passions within cardiology, and part of the reason is because it's an area in which we have to focus a lot of attention. 
It can be very challenging to treat, but if we're able to help people, it's very rewarding. 
We'll see in one of the upcoming slides why that is the case. 
Very prevalent disease.
There's around 6.7 million Americans living with heart failure today.
And if we look at it in closer detail, the probability of one of us having heart failure in the population is about one in every four. 
So it's a very common disease that carries a lot of morbidity, a lot of mortality, and costs a lot of money to treat and to take good care of our patients. 
There's about 4 million hospitalizations every year involving heart failure, and one in every 13 patients admitted with heart failure.
They can develop other conditions, such as infection, kidney disease, which makes it a bit more complicated to treat, to get better, prolonging the hospitalization, and with that, increasing the risk of death within that hospitalization.
What are the most common signs and symptoms that patients start experiencing when they end up in this condition where they have to be hospitalized. 
Most commonly, they start feeling short of breath.
They can't breathe. 
Typically, one of our patients is used to going out to do groceries, pushing their shopping cart, all of a sudden, just getting out from the car, walking into the store, they have to stop a couple times to catch their breath.
One of the other things that we commonly see is that they tell me, doctor, I'm gaining weight, and I don't know why I'm eating the same thing I always did, but all of a sudden,like, I get on the scale compared to when I was here a few months ago, I'm 15 pounds heavier.
And they start retaining fluid, their legs start getting swollen, their socks aren't fitting, their shoes aren't fitting. 
And this is one of the first signs we start seeing that ultimately leads to a cascade where they all of a sudden are very short of breath, can't breathe, and end up in the hospital. 
This is just showing what the numbers look like.
Back in 2017, the total prevalence of heart failure was about 6 million people.
Gradually creeping up. 
The projections are that by 2030, we'll have approximately 8.5 million people living with heart failure.
And so it's a condition that's getting more and more prevalent every day.
We do have a lot of treatments available, but it's a very difficult disease to treat, and that's why we're seeing this trend moving forward. 
Well, thank you. Thank you.
So that's great. 
Summary of the epidemiology and the basic signs and symptoms of congestive heart failure. 
So let's see how much people are paying attention.
So here's our number three quiz question. 
Which of the below is not a common symptom of heart failure? 
Shortness of breath, warm hands, difficulty lying flat, edema, or severe fatigue. 
Oh, my God.
You guys are, like, ridiculously smart. 
Warm hands is correct.
All the others are very common things that we see in patients with congestive heart failure.
And if you have them, especially if your condition has changed relatively suddenly, you should be concerned about your heart. 
All right, Doctor Green.
Doctor Green is our electrician. 
He puts devices in to help people that have congestive heart failure. 
But he's going to focus his attention right now on what causes congestive heart failure. 
The floor is yours.
Thanks for having me again. 
We always enjoy doing these thoughts.
Thanks for coming in, taking time out to be here, and we.
I'm excited to get it to the end so we can open it up so that you can actually access and shoot some hours at us. 
There are a few of my patients in the audience as well, so I ask them to behave, but they're good. 
There are two flavors of heart failure.
There is the squeeze and the inability to relax. 
So the two types of heart failure are called systolic heart failure. 
That's the pumping part where the heart is so weak that is unable to pump blood out, but the heart can only pump what comes to it and what comes to it from the lungs. 
When the blood gets reoxygenized, the heart has to relax to collect that blood, tend to squeeze it out.
So there are two varieties. 
We call it the fancy words of systolic and diastolic. 
But that's basically what that means.
Heart failure, when that occurs, will lead to congestion.
So the blood coming back from the lungs can't get into the heart.
So you have the shortness of breath and the fullness, and the blood coming back from the rest of the body can't get back in as well. 
And therefore, you get your big liver and the swelling of the legs and something we call ascites fluid around the heart.
So, Trevor, can you have both flavors at the same time?
Can you have vanilla and chocolate simultaneously?
Yes, indeed we do. 
In the early days, we only concentrated mainly on the systolic, the inability of the heart squeeze. 
We thought that relaxation the heart to relax and collect blood was not an active process, but we've since determined that it is.
So you can very well have a normal squeeze and have a nice, good, what we call ejection fraction, to squeeze the heart. 
But if that heart is not relaxing properly, we call it diastolic dysfunction. 
That's a failure of adequate relaxation that can also present, just like, heart failure, and it's problematic.
It's actually more challenging to treat. 
Conditions that lead to heart failure include blockages in the heart, atherosclerosis, coronary artery disease, as we call it.
When that gets really bad and completely blocks the vessel, then you get a heart attack.
The real McCoy. 
Know, the Sanford and son boo.
Elizabeth, I'm coming. 
But that's for men.
Women, unfortunately, don't necessarily have that kind of symptoms.
Women present with very subtle weakness, tiredness, and everything else.
So we've learned over the years to pay attention to that kind of a heart attack.
High blood pressure, very, very common 
African Americans in the room.
If you live long enough, you will get high blood pressure.
That is our destiny. 
And the only way to change that, basically, is to change your parents. 
But it's a little too late for that now, so you got to treat it and you got to be very aggressive about treating it.
High blood pressure is not going to come out with a storm and hit you when it does, that's a bad thing. 
It's silent.
It's called a silent killer. 
Damage to the heart valves, it's more often than not, a product of aging. 
Too many birthdays.
As you get older and older, the valves are working back and forth, and there are a lot of other different conditions that will cause calcium to develop on those valves, and that becomes a problem. 
Heart muscle infections are a little tricky.
In the early days, we would talk about virus. 
We see a young person coming to the office during heart failure, have no clue why that might have happened.
That is a. 
We usually say that it's a viral illness.
Of course, we don't know what it is, so we call it idiopathic.
You know, you like sexy words, but we didn't know. 
Now we have a whole different genre of infectious diseases, notwithstanding Covid, that we all know very well, and that can sometimes lead to heart failure. 
The infiltrative diseases, meaning the buildup of different products in the muscle itself, leading to the inability to relax and the inability to squeeze. 
Amyloid, as you see on the screen here, is the newest one. 
That's the sexy one.
We are into a lot of amyloid and treating amyloid because previously, we never used to look for it.
But you see what you look for and you recognize what you know.
Now we are seeing more than congenital heart disease and pregnancy well, around for time immemorial. 
Pregnancy, of course, is the biggest stress test that any woman can have. 
And it is not unusual to have heart failure in and around pregnancy towards the end of it and a few weeks after as well.
Chronic fast heart rates, if you have atrial fibrillation, is the commonest of them all, and your heart is going very fast, like any great stallion or racehorse.
If you don't let it rest, it will run out of gas and get weak.
And therefore, one of our common areas of heart failure, of course, is atrial fibrillation and then severe lung disease. 
Smoking asbestosis.
But smoking, of course, is the commonest of the heart lung conditions that can lead to heart failure. 
All right, well, thank you for that nice little summary. 
So let's talk a little bit about our fourth quiz question. 
We always like to remind people that diet and physical activity are hugely important when we treat cardiovascular disease.
And so a bad diet can make heart failure worse. 
And usually this involves salt intake or sodium content of foods. 
Who here reads the labels before they purchase things or before they eat things. That's great. 
Look at that.
A solid majority of the folks here. 
So let's give you a little quiz.
Now, this gets a little harder. 
Which food item has the highest sodium content? 
Okay, is it one veggie burger?
Is it one cup of cottage cheese? 
Is it one bagel or one can of tomato soup?
Okay, well, that's interesting. 
Well, let's do a vote.
This is a little bit trickier. 
We gave you some easier questions.
This is a harder one. 
So who says one veggie burger? No one. Okay.
Read the veggie burger packages. 
They put a lot of stuff in those veggie burgers just to be careful. 
Yeah.
Okay. 
Who says one cup of cottage cheese?
A couple people. 
Who says one bagel?
Who says one can of tomato soup? Interesting. 
Who wants a hint?
Okay, I'm going to give you a hint. Okay. 
One cup of cottage cheese. There you go.
So believe it or not, unless you read the labels, you wouldn't know these things.
You wouldn't know these things. Yeah. 
So you always have to be careful.
And the take home lesson is, please read the labels.
Okay. 
With that transition, obviously, diet and exercise are treatments for heart failure, but we have a bunch of other things that we do for folks.
So, Carlos, the floor is yours. 
We have a lot of medicines available to treat heart failure. 
And one thing we have to keep in mind is that not everyone will be eligible or appropriate to take or tolerate these medications.
There's this long list of medications that we use, and just to do like a quick summary given this extensive list, that we try to use diuretics primarily or the water pills or fluid pills when you're in the hospital to try and get you to that right balance, fluid balance that you need to be in order to feel better. 
And the goal of the therapies that we have available for heart failure are, I try to synthesize them into, number one, improving your quality of life, making you feel better, number two, making you live longer, improving your mortality, and number three, preventing from hospitalizations.
Preventing these hospitalizations. 
Those are, to me, the three keys in heart failure treatment. 
And we have all these medicines available that we can use. 
The main thing, I think, is if you've been diagnosed with this condition or if you've been experiencing any of these symptoms that we've been talking about, it's making sure you follow up with your doctors, whether it's your primary doctor or your cardiologist, make sure you keep in line with your follow up visits.
And we can then assess which one of these therapies that we have available are appropriate for you. 
Cause there are a lot of limiting factors which include do you have low blood pressures and you're not able to tolerate these medicines?
Do you have other conditions such as type one diabetes, kidney dysfunction, where some of these medications which have in fact been proven to decrease mortality, we may not be able to use it in your case, but we have this long list of medications there which include traditionally well known for long periods of time. 
The ACE inhibitors, one of the class of medications that have been demonstrated to decrease mortality in patients that have heart failure. 
The aldosterone antagonists that we have been out for quite some time in the market, and we're coming up with new medications that may have less side effects and mabe more tolerable in our patient populations.
The angiotensin receptor blockers, the ones that my patients called the tans, the losartans, the valsartans, the beta blockers, which have been out for many years.
And it's also one of the medications proven to decrease more mortality.
The metoprolols, the carvedilols, those types of medication, a very medication that's been out there for quite some time. 
Digoxin was one of our initial medications which we had available in order to help our patients with heart failure.
It's still useful in a certain subset of patients, and I use it quite a bit for these groups of patients, especially when not only the left side of the heart's affected, but also the right side of the heart's affected. 
The isosorbide dinitrates, this very successful medication in improving mortality. 
The angiotensin receptor neutralizing inhibitor, that's the one that you hear out there. 
Entresto, that's a great medication, as well as the SGLT, two inhibitors like Farcica jardians, which were initially created to treat diabetes.
And we found in the last few years that it's probably our most effective heart failure medication we have available. 
But keep in mind what I said at the beginning, not everyone can tolerate these medications or appropriate to receive these medications.
Then we also have this other medication which can be very effective in a subgroup of patients, the Verkuvo verisicle medication. 
So we have all these medications available, and it's our job to try and piece together with you which one is appropriate to treat you to achieve our goals, reduce hospitalizations, make you live longer, improving your mortality, and improving your quality of life. 
Thank you.
So I have a couple of quick questions for you. 
Historically, we've used, quote, triple therapy for patients with congestive heart failure. 
So you gave us a laundry list.
What does triple therapy mean? 
And is that even relevant in the year 2024?
It's relevant to this day when we say triple therapy is using our known horses that improve mortality in patients with heart failure. 
And these can be the ACE inhibitors with angiotensin receptor blocker, the beta blockers, and nowadays with the entresto out there, the SGLT2 inhibitors, and we can even extend that to quadruple therapy.
But it's a lot. 
Some of these medications can interact with each other. 
It can be very challenging to have every single patient on with these medications. 
And depending on the comorbidities, we may not be able to use them all together. 
But they're still very valuable medications that we use nowadays day. 
And they're the mainstay of our treating our patients with heart failure. 
Fabulous.
And the order of these things is not random. 
So on the top of the list, all but the last three classes are generic i.e , cheap 
They're inexpensive for patients and they're listed in alphabetical order, not in the order of usefulness.
Just so you know, the last three are expensive. 
As mentioned, the Angiotensin receptor blocker with neprilysin is entresto. 
There's only one drug in the market.
My patients are constantly struggling with how to pay for that.
I'm sure you guys have the same thing. 
The SGLT2 inhibitors are things like farxiga or jardiance and they're expensive. 
And Verquvo is another one that's a unique drug that's also quite expensive. 
So the cost is definitely an issue, and as mentioned by Doctor Henriquez is that some of these have specific niche categories.
Remember Trevor, 15 years ago you and I were talking about the isosorbide dinitrate hydralazine combination for african american patients. 
You want to comment on that?
Yes. 
You mentioned costs, and cost is so.
And we will touch on it in the next topic. 
The combination of isosorbide dinitrate and hydralazine. 
There was a drug out there called Bidyl, probably about, would say five or six years, be COVID. Covid is a really good landmark for putting on a landmark. 
We had this dru Bidyl and it worked beautifully for African Americans in african american subpopulation.
The problem with it was that it was getting it made.
The company literally ran out of business because you just couldn't get the volume.
So economics became a very important part and the, and the fall of that medicine, and we'll probably talk about economics a little bit more as well. 
Well, Trevor always teaches me something at these meetings. 
So now I know that BC, when you talk about dates, is before COVID. 
Before COVID That's exactly right.
So just a quick summary. You kind of mentioned this, but just to emphasize the goals of treatment for CHF. Carlos. 
Yes.
Becoming aware of the initial symptoms that we talked about at the beginning.
Are you feeling short of breath? 
Are you noticing some swelling in the legs?
Have you noticed a decrease in your exercise tolerance?
And that's very important, educating our patients to make sure that they understand that these are the things they need to be looking out for, and in order so that we can start treating them to improve their symptoms and quality of life, hopefully halt the progression of the disease and reduce the likelihood of requiring hospitalizations and improving mortality, making you live longer. 
That's the main emphasis that I place on when I deal with patients with heart failure. 
How about a quick note about some of the procedures we do to treat heart failure? 
So we have several procedures available.
The first one here on our list is the defibrillator, ICD placement.
Just. This is not something that's gonna treat your heart failure per se, at least the ICD.
It's basically what one of my professors used to always say is there is an insurance policy, like if, when you have heart failure, you have a slightly higher risk of developing life threatening arrhythmias. 
And what this defibrillator does is a special pacemaker that detects that, and it's able to protect you and try to get your heart out of this dangerous arrhythmia so that you don't suffer sudden cardiac death.
We typically reserve that for patients that have either had a previous life-threatening event that's been documented, whether in the hospital or somewhere else, on a monitor, or in patients that have a very weak heart muscle. 
And despite being treated with the therapies we described before, their heart muscle remains weak. 
So these are the people that we reserve the ICD for the CRT. 
Cardiac resynchronization therapy is a special type of pacemaker, where we add an extra wire that goes to the left side of the heart, and it tries to cause a synchrony between the left and the right part of the heart.
The heart's a very smart organ, but it needs synchrony, whether it's between the upper and lower chambers or the right side and the left side of the heart.
And we have found that with cardiac resynchronization therapy, if you're a candidate for it, to restore that resynchrony goes a long way in making you feel better and also decreasing the morbidity and mortality of the disease. 
The left ventricular cyst device is basically a pump, a pump that's surgically implanted in the left side of the heart, right at the left ventricle. 
And it's extensive surgery, as you can imagine, having a pump in your heart. 
But in some people in which they've been, haven't responded well to medical therapy, their heart remains very weak and they're constantly being hospitalized. 
These are the people that we refer for an LVAD implant, and we also have heart transplant when we can either use the LVAD as like a bridge to the heart transplant, or if we find an ideal candidate with matching donor, we refer for heart transplant as well. 
There's also another type of procedure that I just briefly wanted to mention, because I have encountered patients that have heard about it, whether Facebook support groups and things like that.
The barrel stim, which is a type of pacemaker that's placed, that brings up a wire to the carotid artery, and it tries to stimulate a neurohormonal response to the heart to try and make it work in a more efficient way. 
So that's another thing that we have available. 
We actually did the clinical trials for that here in Jacksonville. 
I don't know if you remember that.
The barrow stem system, which stimulates the vagus nerve.
When we first did it, we had these big patches on the carotid arteries that created the vagal stimulation. 
And nowadays it's just a much smaller device like a pacemaker that just stimulates one of the carotid.
So thanks for bringing that up. 
Yeah.
And the one thing I will say is, if you've heard about it, talk to your doctors about it.
Not everyone's a great candidate for it. 
So make sure you have that discussion with your cardiologist. 
Listen, I'm not doing that great.
I've been hospitalized a couple times. 
I've already tried these medications.
Am I a candidate for any of these things? 
And these are discussions that we should all be having together when we see patients with heart failure in our offices.
Excellent. Thank you. 
All right, so getting a heart transplant is an expensive procedure. 
Doctor Green has mentioned previously some of the economics of heart failure. 
So, Trevor, let's flesh that out a little bit for the folks about why there's such a huge economic burden in the United States.
Well, the numbers speak for themselves. 
Pretty, pretty expensive. $40 to $60 billion a year. 
That's billion with a, b, of course, we now live in a society where we for around billion a million means nothing these days if you're a millionaire, really nobody, billions is the issue. 
But if we look at the progression, we can be looking at some very close to $70 to $80 billion by 2030 just to deal with heart failure alone.
So it's a big project. 
The majority of the patients, of course, will be in Medicare. 
And we all know the burdens that Medicare is going to face as we go forward. 
Why medicare?
Because the majority of heart failure occurs in elderly patients.
And past 65, we are all eligible to get into that pool of patients.
So that's a topic that continues to be nagging us. 
How do we actually manage it?
But prevention is better than cure. 
So one of the ways that we can harness the cause is to try to prevent the heart failure. 
To begin with.
This is still the best approach in that department.
When heart failure does occur, we have to be very aggressive about treating it, because every time you come back to the hospital, it gets more and more expensive.
So again, keeping patients out of the hospital by good care.
And what do I mean by good care? 
Understanding what the problem is.
So when you visit your doctor, make sure you take a spouse or a significant other with you, because that's very important time to understand what is happening.
And there's so much coming at you that you will not, you turn off.
So you need a spouse with you to handle that conversation.
And then the biggest problems, basically, where heart failure occurs, as you can see here in the winter months, and that is pretty intuitive, and it falls off in the late summer months.
But costs are a big issue, and we struggle to keep costs.
One of the things that I would like to mention while I have this opportunity is that the list of medicines are long, and therefore, compliance is the fancy word that we use.
But do you use them, the beautiful procedures that doctor Hendriquez talked about with respect to devices? 
I do those kind of devices, but long before you get to those devices, I work on patients, and I have a few of them in the audience. Compliance with the medicine. 
The medicine is the gasoline. The devices that we put in are all nice and sexy, but if you put, if I give you a Lamborghini and you only put an in kerosene oil, it ain't going nowhere. 
The medicines is the gas.
The medicines is the thing that will keep you out of trouble and prevent you from having to go on to these medicines. 
Now, the challenge that we find is that these last three medicines that we mentioned, they're a thing of beauty.
I've been doing this a little while, and what I've seen is that with the new medicines that we have now, the last three medicines on that list are actually decreasing the number of devices that I have to put in to help patients. 
And if I've been actually waiting a little longer and insisting that patients remain very compliant with their medicines, because there's always a chance that the medicines can work and we do not have to resort to putting in the mechanical stuff, you see, again, costs. 
So those are the kind of little things that we are doing to try to get the cost down. 
But unfortunately, the medicines are so expensive.
The newer guys, in the last ten to 15 years, we have gotten some very powerful medicines that Doctor Henriquez described, but unfortunately, they are very expensive and we struggle with insurance. 
It's a constant battle every day to have insurance is recognized that at the end of the day, if we can get.
If we can treat this cost upfront and we don't have to wind up putting in expensive, sexy devices that you literally actually save money. 
But of course, we are a society that move quarter to quarter. 
People make their decisions on profit and loss based on quarters, and it's hard to think down the line at what.
So that's a challenge, and we're living it every day. It's so important.
You can see in the bottom of this slide that the cost over a decade for treating congestive heart failure has gone up 23.7%. 
And there's a lot of emphasis and research to figure out how to prevent the hospital component of it, which is the most expensive component.
So, for example, we're doing clinical trials now where we're looking at tracking devices to see if we can detect worsening congestive heart failure as early as possible.
And so thank you for you guys participating in those studies.
So this is a real focus for research, is to try to keep people out of the hospital and identify problems as early as possible, and as Doctor Green mentioned, to use medicines that prevent the problem in the first place so that we can save costs downstream.
So that gets into a little bit about research, which is an area that I love and is sort of my passion. 
And this is really interesting.
This is just a bit ironic, but when I was a cardiology fellow in New York City a zillion years ago, I think that was definitely BC Trevor. 
I wrote a review article about congestive heart failure that was focused mostly for the lay population.
And I made the observation in 1991 that very little has changed in treatment over the last 30 years. 
So between 1961 and 1991, when I wrote this article, very little had changed. 
Can we say that for the last 30 years? No.
No. 
There's been unbelievable changes in congestive heart failure treatment in the last 30 years, like mind boggling changes, including using devices which we thought would be crazy. 
So Doctor Green is electrophysiologist. 
He puts devices in, and we can do things like resynchronization therapy, as mentioned by Doctor Henriquez, that can actually improve the heart muscle function over time. 
The converse of that is that if we use pacemakers that are not synchronized, it can make it worse. 
So it's just astounding how much progress we made over the last 30 years. 
But I'm going to predict we're going to make even more progress in the next 30 years. 
And that's because we have a better understanding of the biology of congestive heart failure, what drives it.
And as you understand the biology, you can intervene and make a difference earlier on in the disease.

So this just shows some of the approaches that we're working on as we speak. 
So if you're interested or you know somebody that might be interested or might benefit from these things, sign up, write it down on your sheets, let us know what your concerns or what your medical conditions are, and we can match you with the right program that could be a benefit to you. 
All these programs are free of charge.
We don't take your insurance information. 
This is all funded by external sources, so we're looking at better monitoring devices. 
We talked about that.
We actually did a study with Samsung to see if their new watch could be better predicting cardiac events. 
Neurohormonal blockade is key.
So drugs like Entresto block the bad hormones that make heart failure worse.
And we understand that better and better, and we're coming up with better and better products to prevent that from making your heart get weak or get really stiff.
The naturitic peptides are naturally occurring chemicals that help your kidneys get rid of that extra fluid. 
As mentioned, for systolic dysfunction, there's a weakness of the heart muscle. 
So we're interested in using contractile agents.
The one that we have on the market now that's been around for a long time is digoxin.
And we recently have another one that can help with contractility that is super expensive, $100,000 a year. 
So it's really not practical for most patients.
But we're trying to come up with better ideas to help the heart muscle contract better.
The other thing that we've learned is that there are anti-inflammatory effects that can help the heart muscle over time. 
So there was a study that was done a few years ago that looked at people that had heart disease with high levels of inflammation, and it turned out the drug is called canakinumab, and it works to reduce inflammation and improved outcomes, only about 10%. 
But again, because it was an expensive drug that the manufacturer thought that they couldn't necessarily sell, they ended up not putting on the market for heart disease. 
It is on the market for childhood rheumatoid arthritis, interestingly. 
But it's a drug that is triggering the inflammatory cascade, which makes heart failure worse.
And we mentioned SGLT, two inhibitors. 
They were really interesting because we started doing the research on these drugs to show they were safe for diabetes.
So drugs like Jardiance and Farxiga, which are now marketed for Haart, were developed as diabetes drugs. 
And the FDA, in its wisdom about 15 years ago, said, well, any manufacturer that sells that new diabetes drug has to show it's safe for the heart.
So we did these studies, and lo and behold, not only were they safe for the heart, but they actually seem to improve heart muscle problems and reduce bad heart outcomes like heart attacks and strokes. 
So instead of just using them in diabetic patients, we now use them in all patients. 
So this is considered now standard therapy with anybody that has a weak heart muscle or has a stiff heart muscle.
So, remarkable progress over 30 years. 
And this just gives you a quick view of some of the things that we're doing now. 
And this gets really, really technical, and I'm not going to go into all the details unless you are interested.
I'm happy to give you a little bit of a biochemistry lesson if you choose, but I'm not going to bore everybody with that at the moment. 
But all these things are looking at very specific biochemical pathways and way of treating them. 
The only one that I will mention, because it's super interesting, I think, is this number two on the list, which is targeting something called relaxant. 
So we mentioned the fact that during pregnancy, there's a huge stress in the heart. 
The amount of volume in a woman's body increases dramatically. 
But developing symptoms of congestive heart failure during pregnancy is actually very rare. 
So people are thinking, well, how is that?
How can women, over a very short period of time, get all this extra fluid, put on this weight and still not develop congestive heart failure? 
And we believe the reason for that is a hormone called relaxin, that pregnant women make in very high levels.
So now we have ways of producing relaxin and giving relaxin to non pregnant people that have congestive heart failure. 
And as we speak, we have studies that are looking at that exact mechanism. 
So we have all kinds of cool things that we're doing. 
And again, if you're happy, all this stuff will be on our website. 
And if you have any questions, you can go through the details with you.

Thanks for joining the MedEvidence podcast.
To learn more, head over to medevidence.com or subscribe to our podcast on your favorite podcast platform.