I'd like to welcome everybody today to the Heart Failure Society of America in the Needy Meds Patient Education Webinar. My name is Robert Page. I'm a professor in the Department of Clinical Pharmacy and a cardiology clinical pharmacy specialist at the University of Colorado. Today's presentation is entitled Emotional Wellness and Heart Failure and the Caregiver Challenge. And we will be discussing the various moods that affect a heart failure patient, how to recognize these mood changes, when to seek help and treatment options available, and again to offer some support and information from the Heart Failure Society of America. Now this presentation will also address the important role a caregiver plays, the challenges and rewards of caregiving, the importance of self-care, and also finding support when needed. Now we could not provide this wonderful information without the thanks for our sponsors. And our sponsors are Abbott, Amgen, AstraZeneca, and Cytokinetics. And they have provided an educational grant to support the development and dissemination of our patient and caregiver webinars. So it is with great pleasure today that I am able to introduce a very world-renowned cardiologist and heart failure specialist who I know very well, Dr. Nazarene Ibrahim. And she is an assistant professor of medicine at Harvard Medical School and associate director for resynchronization and advanced cardiac therapeutics programs. She also serves on the Heart Failure Society of America patient committee. Now we would like this webinar to be as interactive as possible. And as such, we encourage you to submit your questions to our presenter using the questions tab. And that can be found on the left side of your screen. Please feel free to submit your questions at any time. The question and answer portion of our program will immediately follow this presentation. We would also like to point out a great feature for those who wish to take notes during the presentation. When you click on the notes tab on the right side of the screen, you will see a white box. And it's there that you can take notes on today's webinar. And these notes will be emailed to you automatically at the end of this presentation. So it's great pleasure again that I'm able to introduce Dr. Nazarene Ibrahim, who is going to be talking again on emotional wellness and heart failure caregiver challenges. I will turn it on over to you. Thank you so much, Dr. Page, for that wonderful introduction. And again, I'm Dr. Nazarene Ibrahim. I'm very happy to be here today to talk to you about a very important topic that's important not just to the patients that have heart failure, but also to the caregiver that do incredible work helping us manage such a complex medical condition. So we will start with just letting you know and letting the patients and the caregivers know that mood changes are very common in patients with chronic health problems, including patients with heart disease that includes heart failure, patients that have had heart attacks, patients that have had valve surgeries, diabetes, patients with lung disease, and also patients with kidney disease and stage renal disease and patients on dialysis also have mood changes that affect how they are managed in their chronic health conditions. So it's important to recognize the common emotions and heart failure, and they are and some of the ones that are most common are anxiety and fear, sadness and depression, especially when a patient is first diagnosed with heart failure and understands that this is a chronic and lifelong condition that requires lifelong medications most of the time, irritability and anger that not only affects the patient, but also affects everybody around the patient, including friends and family members, frustration, because a lot of times it's difficult to know what the trajectory of heart failure is and where you will be in a year and how you'll be feeling maybe even next month or how you're going to make it through the holidays. So frustration is very common. Guilt is also common because patients feel like they're a burden to their loved ones and their friends and their caregivers. Loneliness is also common because a lot of times patients, when they're first diagnosed or when they become very ill towards the end stages of the disease, they're not able to do the things that they normally do, including maybe going to church or working. And so they get into a bubble and the sense of loneliness can become overwhelming sometimes. And then finally, of course, stress. Stress involves with the diagnosis and then stress involved in everything that goes into managing heart failure, including the multiple medications, hospital admissions and frequent clinic visits. And so why is this important? Why are we talking about this today? Because it's important to note that these emotions affect your overall health. And I tell my patients all the time, the heart and the brain are interconnected. And so if the mind's not working and if the mind's not in a good place and you're not in a good, you know, a good state of mind, it becomes really difficult to manage everything else. So for example, a patient that has depression and has difficulty just getting up and getting out of bed every morning, it's difficult to expect them to take all their medications, to come to their clinic, follow up appointments, to come to cardiac rehab. And so that interconnection between the mind and the heart and the rest of the body is really important to manage. So again, patients are less likely to follow a treatment plan. Patients may have a slower recovery from heart failure. And then emotions like anger and stress actually make the heart rate and blood pressure go up, which in turn makes the heart harder to work. So you get in a state where your blood pressure is high, your heart rate is high, and now your heart's working harder to keep up with the demand. And then also several studies have shown that ongoing depression can increase the risk of having more cardiovascular events and also more heart failure hospitalizations. And so that's why we're talking about this and that's why we want to give you practical solutions as to how to manage these mood changes. And so how do you recognize these mood changes? Sometimes the patients may recognize the mood changes themselves, but oftentimes it's usually the caregivers, friends, and family members that notice changes in the behaviors of the patient. So it's great when these caregivers come to the hospital admissions or the clinic visits and let us know that things have changed. So things like fatigue, and sometimes it's difficult because heart failure itself can cause fatigue, but sometimes the fatigue is just out of proportion to how bad the heart disease really is. Things like feeling down, trouble concentrating. Sometimes patients say they can't get through reading a newspaper anymore because they just can't focus like they used to. Irritability. Sleep pattern changes are common, and that can mean oversleeping, but it can also mean lack of sleep and insomnia can be a sign of a mood disorder. Appetite changes. Sometimes patients gain weight, but patients sometimes actually lose weight because they're not eating like they used to before. Lack of interest, and think of these as, you know, activities that you had interest in doing before, but now you, you know, you have no desire to do the things and hobbies that you used to like doing before. Withdrawal from other people and isolating yourself, saying, you know, the things that you did socially with either church members or family, friends, you're not doing anymore. Excessive worrying can also be a sign of a mood disorder. And then feeling worthless and guilty, like we had mentioned before, and suicidal feelings. And so suicidal feelings become a medical emergency when you have feelings of either hurting yourself or even thoughts of a plan, and that's when you should seek emergent medical care, and we'll talk about that later as well. And so we've talked about all of these things that can happen, and I'm not saying these to overwhelm you because we can do something about these mood changes that are very common in patients with a chronic disease like heart failure. And so the first thing after recognizing that something may not be right is to start a conversation. And it's difficult because there's a lot of stigma associated with mood disorders, but talking to a trusted friend or family member is a good first step. And then secondly, there's support groups. There are support groups that are associated with different clinics and hospitals, but there's also support groups in the community, and it's very easy to find these online, actually. And if you don't want to go somewhere that's connected to the hospital, then maybe a neighborhood support group would be the better option. And then finally, and very important, is to talk to one of your clinicians about treatment options and emotional support. And so if you have a good relationship with your heart failure nurse or pharmacist or your physician, it's important to start these conversations. And I think we as clinicians and physicians and healthcare workers don't do a great job about asking about mood. We really need to do a better job, but also it would be helpful for us when the caregivers and patients let us know that things are not going as well as they should because sometimes we focus a lot on the disease itself and heart failure medications and maybe talking about transplants and future surgeries, but, you know, sometimes we have to talk about the basics and one of the most important things is to say, you know, is your mood okay? Is your mind right? Are you in a good mental space so that we can make everything else easier to manage? It's also very important to actively engage in your health. So we talk about exercise all the time. And for some patients that aren't used to exercising, cardiac rehab may be a great option because they start you off slow and they gradually increase the amount of exercise you're doing. You can start with even just five minutes a day and gradually increase the amount of exercise you're doing. Also starting a new activity, a new hobby or maybe an old hobby that you want to pick up again and then taking an active role in your overall health including nutrition because nutrition is very closely connected to mood, self-care overall, and then medications. And then when to seek help. So I talked about seeking emergency help when you have thoughts of suicide or you feel like your life is not worth living or if you even have a plan for suicide, so that's an emergency and you should seek immediate medical attention for that. But some cases that are less severe, if your symptoms are severe, they're lasting for a long time and things aren't getting better when you've tried certain things like exercising, going out more, changing your diet and you still feel like you're struggling, that's when you should seek help. And also you should seek help when now your symptoms are interfering with your daily routines and with your quality of life. So struggling to do the things that you normally like to do or even struggling to do basic things like getting out of bed and cooking for yourself and putting your clothes on, doing your hair and makeup and any other thing that you consider a daily routine of life, when those things become difficult, it's important to ask for help. And what are the treatment options? So there's a lot of treatment options and counseling and therapy can be by a psychologist, a psychiatrist and also social workers as well can provide counseling and therapy and medications. And it's important to note that medications don't always work on their own, they're excellent therapies for a lot of mood disorders, but a lot of times counseling goes hand in hand with the medications or you start medications and you start group support therapy or you start your medications and now you start a new hobby or an exercise routine. So a lot of these go hand in hand to really get the best results. And we've talked about a lot of these symptoms, fear, phobia, stress, anxiety, panic, worry, feeling hopeless, but it's important to know that there is hope and we have ways to manage these mood disorders. And first and foremost, before we go into talking about your heart failure and your medications and your cardiomyopathies, we have to make sure that you're in a good mental space and that your mood is well controlled. And so switching gears here, we're going to talk about the caregivers because they are a key part of the management of patients with heart failure and we really would not be able to do what we do as clinicians without the support that is provided to us by caregivers. And so what is a caregiver? A caregiver is a person that helps a patient with heart failure live as well as possible with the disease. So a caregiver can be anybody. It could be a friend, it could be a parent, it can be a child, it could be a spouse. Some patients have several caregivers, some patients only have one or two caregivers. And so the role of the caregivers really is key and they accompany you to doctor's appointments. They help with daily activities including diet and exercise. They help patients sort their medications and make sure patients are taking their medications on a daily basis. They also watch for symptoms of heart failure because sometimes patients with heart failure don't always realize that they're getting worse, but when they have a person that's been with them throughout the duration of their disease, sometimes the caregivers are able to tell us clinicians that, hey, things are not actually going as well as they were last time we saw you at an appointment. And then of course caregivers provide emotional and social support for the patient. So that feeling of loneliness that sometimes heart failure patients have, patients with caregivers are less likely to have feelings like that when they do have that emotional support system with the caregivers. And so as a caregiver that's providing support to our heart failure patients, it's important to note that they too can suffer mood disorders including stress, anxiety, feeling burdened, and feeling a lack of support because, again, they're providing all of the support to the heart failure patients, but there's not necessarily somebody that's supporting them. And this was a great quote from a caregiver of a patient with heart failure. And they said, I've never felt caregiving was my gift. I tend to feel I'm being imposed upon at times that you are being called upon. And so it tells you that sometimes caregivers feel like this was what, you know, this challenge was given to them and that's what they were made to do and that they see no other way other than supporting their loved one, whether it's a friend or a family member that has a chronic illness such as heart failure. But there are rewards of being a caregiver, and caregivers have reported feeling gratitude, feeling a sense of fulfillment and satisfaction, and also feeling thankful. And here we have another quote from a caregiver of a patient with heart failure. It was some of the most blessed time we had together, it really was. It ended up being such a blessing. And what we tend to see with caregivers is that they actually end up knowing a lot about heart failure. They are educated because of how much time they spent with patients with heart failure, all the appointments they're coming to, they end up knowing the meds inside out. So it's a great resource and us clinicians could not be more thankful to the caregivers that some of our heart failure patients are lucky to have. But it's important also for the caregiver not to lose themselves in this process because heart failure is a chronic illness and it's, you know, it's a lot of work to be there to support our heart failure patients emotionally, physically and with whatever else they would need. So it's important for the caregivers to take care of themselves, to get enough sleep, exercise regularly, eat well-balanced meals, ask for help when they need it, and also join a support group for caregivers. And so I always say, you know, don't lose yourself in this process and that you have to, as a caregiver, still have to have your escape outside of heart failure, your escape outside of providing all of the support for the heart failure patients so that you also can take care of yourself and have a well-balanced and good mental health. And so there's lots of resources and support for patients and caregivers and the Heart Failure Society of America is one of the best resources out there and you can see the website there. There's also Mended Hearts, Women Heart, Caregiver Action Network, and Needy Meds all have great resources for patients and caregivers. And then there's also local resources and so it's important to ask your heart failure clinicians, pharmacists, nurses, physicians, what other support groups are available through the hospital or even just neighborhood support groups that the patient and the caregiver can attend. So as I mentioned, the Heart Failure Society of America has a heart failure study patient tool. They have educational resources for patients and families and caregivers. And so if you go on the Heart Failure Society of America website, there is a patient tool tab and you can learn more about educational models, risk assessment toolkits, and then there also is a heart failure app called Heart Failure Health Storylines that has several patient stories because I feel like as clinicians, we can talk, talk, talk, but if you talk to people that have the diagnosis of heart failure itself or caregivers of patients with heart failure, you can really get more information of how they've been able to cope and practical advice on how they've dealt with the challenges that have come up. And I will turn it back to Dr. Page now. Thank you so much for that wonderful presentation. So now we are going to be turning to our question sections, particularly those that have been submitted. However, please feel free to continue to submit your questions using the question tab on the left side of your screen. All righty. It looks like we do have a few questions for our speaker. The first, actually this is, so Dr. Ebrahim, we have a patient case. Okay. This is an, okay, we have an 80-year-old female with the following, has a left ventricular ejection fraction of 57% by echo, and that was on May of 2019, 45%, it looks like on May of 2019, 40, let's see, 42% also, so it was repeated, also mitral regurgitation was noted as trace in 2014 and May of 2019 echo reports. And the echo report also said that it was, quote, unquote, moderate in June of 2019. The question is, should this patient see a heart failure specialist or continue to see her highly regarded general cardiologist at the Brigham and Women's, who has not referred her to a heart failure specialist? What are your thoughts on that? So there are way more heart failure patients than there are heart failure specialists. So a lot of our heart failure patients are actually managed by primary care physicians and general cardiologists. So in terms of who the patient should see, I think the general cardiologist at Brigham and Women's or any other hospital can manage heart failure very well. I would bring up the concern that the ejection fraction is dropping. And I would discuss the medications and make sure that this patient is on the appropriate heart failure medication, and maybe get a better look at the mitral regurgitation to see if the patient would qualify for a procedure on the mitral valve, such as a MitraClip. But without more information, I wouldn't be able to provide an answer. But I would sit down with the general cardiologist and talk about the concern of the ejection fraction dropping and the mitral regurgitation getting worse. So you bring up a really good point. You know, a lot of people don't think of the specialization of heart failure within medicine, and that's something really new over the last couple of years. What is your threshold as a cardiologist to refer a patient for advanced, for a heart failure cardiologist? What threshold? When should a patient reach out, though? I would say if the patient is, there's a really good mnemonic called, I need help, and I think it's more technical and scientific than it calls for this webinar. But I would say, you know, from the patient standpoint, if they're not feeling well, if they're still short of breath doing activities that they do on a daily basis, if they're concerned that their ejection fraction hasn't improved in years, if they're noticing that now their blood pressure is running lower than it has been, if they're not able to take the medications, the guideline-directed medical therapies for heart failure, such as ACE inhibitors and beta blockers, because their blood pressure is too low, and the doctors keep, you know, peeling back these medications, all of those are indications that patients should see a heart failure specialist. But I think the easiest one is symptoms. So if a patient is continuously feeling short of breath, if they're in and out of the hospital because they have volume overload, they have lots of edema, and they're just, you know, short of breath, then those are reasons that a patient should see a heart failure specialist. Okay, awesome, excellent. So I do wanna highlight though, for those of you who also are still interested in this particular question, the Heart Failure Society of America just did a webinar last month entitled Advanced Heart Failure, When Patients Should Seek Help. And if you're interested in watching that, it is posted on the Heart Failure Society of America's website. And all you have to do is go under the patient tab. The website is www.hfsa.org. Alrighty, let's turn to our next question. So the question comes and it says, what unique advice would you give for the patients or for, excuse me, for the parents slash caregivers of children in heart failure or those who have undergone a heart transplant? And so the challenges of transplant are very unique and they're different than in patients with heart failure. So my biggest piece of advice would be to speak to parents and caregivers of children who have gone to transplant that have had heart transplants. Again, I work at an adult hospital and I only take care of adults, but I know that the challenges of patients that have received transplant, especially children are very unique. And I think the best source of advice and guidance is other families that have gone through this. And I would say for adults, especially the first year after heart transplant is the busiest and most difficult because that's the year that you get the most rejection. That's the year where you have lots of appointments because you have to come back for several heart biopsies. So it's a very busy year, but after that things do tend to get better. But in terms of the best advice for children that have gone to heart transplant, I would say getting support and advice from other parents that have gone through that. And I know a lot of hospitals have those support groups for parents and caregivers of children, especially. I know sometimes that transition between being a child and then to an adult can be very difficult. And so I know as speaking from my standpoint, particularly from the medication standpoint, because they now have to accept the responsibility for managing some of their own medications. And so with that said, I'm gonna actually ask you a medication question. So one of our listeners just typed in and said, what antidepressant medications tend to have the least amount of interaction with typical heart failure medication? Dr. Page, you are a world renowned clinical cardiology pharmacist. I am turning the question right back to you. All righty, thank you so much. You know, honestly, what has been tried and true has been what we call our selective reuptake, selective serotonin reuptake inhibitors, what we call SSRIs. These particular medications do not seem to have major interactions with common guideline-directed medical therapies. The nice thing about this group is that they have been evaluated in patients who have heart failure. Unfortunately, they haven't shown huge improvements in heart failure outcomes, but patients do seem to feel better with a slight improvement in their functional status. They're cheap, which is awesome, and they're generic. The most common ones, again, are fluoxetine, which is known as Prozac, sertraline, which's brand name is Zoloft, and Paxil, which is paroxetine. It's a generic name. My recommendation is to have this conversation with either your primary care provider or your cardiologist or heart failure, your heart failure cardiologist, to discuss which one, because each one of these have various side effects. Some are very activating, and then some are very sedating, and they do carry some sexual side effects. So those are things that I would, though, address again, and it's a great conversation to have with your physician or provider. My husband has had heart failure for 12 years and now is in advanced stages. We are looking for tools that are more advanced than just a low-sodium diet. His mobility is very limited. What suggestions do you have for advanced heart failure? It's difficult to answer this question without knowing how old this patient is, but this is the exact patient that should be seen by an advanced heart failure and transplant specialist, because if mobility is limited by heart failure itself, that's different than to say mobility is limited by knee pain or back pain. But if it's truly the heart failure that's causing difficulty with mobility and shortness of breath and making just activities of daily living difficult, then we do have advanced therapies, and advanced therapies meaning if a patient is eligible, we would consider them for transplant. And then if a patient is eligible, we can consider them for a mechanical heart pump like an LVAD or a left ventricular assist device. And then sometimes patients are not eligible for a transplant or a mechanical heart pump, and we might have to consider putting them on a medicine that artificially helps the heart pump called an inotrope like dibutamine or milrinone to help with their symptoms. But this is the exact type of patient that should be seen by an advanced heart failure physician or clinician like a nurse practitioner, physician assistant to get more data as to why the patient is limited and what they would qualify for based on not just their age, but also how their other organs are doing. But I would suggest specifically this patient should be seen by an advanced heart failure doctor or nurse practitioner, physician assistant in their area. Awesome. Well, you know, this particular nurse nurse brings up a good point. It's this idea of a low sodium diet. You know, it's interesting, I get the medical students for one week and the pharmacy students for one week to try to keep, to try to conduct a low sodium diet of less than two grams. And everyone comes back to me and says, it is absolutely impossible in today's society. What's your take on this low sodium diet? And what do you recommend to your patients that you're seeing with advanced heart failure? So I don't think, as you know, Dr. Page, there's not enough data to tell us that a low sodium diet is really required. I don't think we have enough data either way to say whether or not a low sodium diet benefits patient, but I actually tell my patients moderate sodium intake for as much as they can to control how much sodium they're taking. And I also have noticed, and I don't know if you have noticed this as well, Dr. Page, that it's very patient dependent. Some patients are very sensitive to sodium intake and just a little bit of going out to eat Chinese food or fast food, the next day their legs are swollen and they have to take an extra dose of diuretics. And some other patients, it really doesn't affect them that much. There's trials going on right now to answer that question better, but I tell my patients moderate sodium intake. And as their heart function gets better and they're taking less and less diuretics, I really am not that strict with the amount of sodium that they're taking. Oh, I know that. I agree with you 100%. I think moderation is the key and it affects also quality of life. Yeah, my uncle has advanced heart failure with an EF of 45% and he's from North Carolina. And as soon as he has one bite of barbecue, boom. He's gotta up his Lasix dose. And so that is awesome and really, really, really good to know. You know, I'm gonna put you on the spot again though. What do you think about fluid restriction? That's another thing that is so difficult for our patients to follow sometimes because things have fluid in them that you don't think about. You know, fruits, those types of things, and it's hard to calculate. What are your thoughts on that? And I'm glad you asked that question because I just saw that question come up in the chat as well. And the big picture of things, the way I practice medicine is quality of life. So I really don't like my patients to feel too overly restricted, whether it's sodium intake or fluid intake. And we hear this all the time, 1.5 to two liters of fluid. And sometimes it's really important to stick to those restrictions, especially when the ejection fraction is really low, meaning the heart is very weak and we're struggling to remove the fluid with diuretics. We put patients on, you know, one liter fluid restrictions, which, you know, it's very tough. It's not, I sort of look at it as sometimes as being inhumane. So I tell my patients two liters, and if I need to increase the amount of diuretics I'm giving them, then so be it. But that's how I practice. And it's very different across, you know, the United States of what clinicians do. But during an admission, sometimes when a patient is very volume overloaded and we're really, really struggling, sometimes it is necessary to be restrictive, but in actual life, when patients are outside of the hospital and they're just really trying to have a normal quality of life, sometimes I don't have a fluid restriction when it's patients that have ejection fractions that have significantly improved. But for ones where I'm struggling, even as an outpatient to keep their volume status normal, then I do occasionally have fluid restriction. But I prefer, you know, to go up on the diuretics a little bit because I really want patients to be able to live as normal of a life as they can with a diagnosis of heart failure. Awesome. You know, we just got a comment from one of our listeners and she says, this is more of a comment than a question. She goes, I am a heart failure patient with HESPAP. So heart failure with preserved ejection fraction. Low sodium diet makes a big difference for me. If people are looking for ideas, recipes on how to eat when traveling, which I know is quite, quite difficult. There are two Facebook support groups that are very helpful. One is called Shaking the Salt and Hacking Salt are the two groups that she knows of. Hacking the Salt has over 12,000 members. And I also want to point out that the Heart Failure Society has information on this as well on their website. And I would recommend listeners to kind of tuning in. She brings up a really good point. By chance, do you treat your HEF-TEF patients any different than your HEF-REF patients when it comes to a low sodium diet? No, for me, the answer is the same. I treat them the same as I do the heart failure with reduced ejection fraction. But this patient brings up the point that I had brought up before that every patient is different. And some patients are just very sensitive to sodium and may have to watch it closer than other patients. But I, again, I just tell my patients everything in moderation. But I did want to bring up also the point about the salt substitutes. Dr. Page, do you think that those are okay? Because I've heard that some of them have high potassium loads in them as well. Yeah, I'm not, you bring up such a wonderful point. I'm not a very big fan of the salt substitutes. And you know, and the reason being is is because they do have, they do have sometimes up to 10 milliequivalents of potassium per serving. So they just simply replace, for our listeners, they replace the chloride salt with a potassium salt. And so in some cases when patients are on high water pills, diuretics, it doesn't seem to be so much an issue. But again, it's so patient-specific that I would recommend not using those at all. I do know that some patients turn to things like Mrs. Dash and other things like that. And I can say sometimes, I like Mrs. Dash, to be honest with you, but I've had some people say it's difficult to cook with and doesn't have the flavor that you have with salt. But my recommendation, though, is to avoid those types of salt substitutes. And what I would recommend is what we tell all our patients is you gotta read the label. Just like with your prescriptions, you know how you read your label in order to know how to take your medication? Same thing goes with foods, is turn it on the back and actually see how much potassium is in there per serving. And so again, I would recommend our listeners to turn to, it's actually module number two in the Heart Failure Society of America's website on how to follow a low-sodium diet. So with that, we actually have another patient-specific question. Is transplant an option for one who has had three ablations and an AV nodal ablation for chronic AFib with no progressive results? Again, I would need to know more about this patient, but in and of itself, atrial fibrillation usually is not a reason that we transplant patients. If the patient has atrial fibrillation and end-stage heart failure, or if the patient has other arrhythmias like ventricular tachycardia that is not getting better despite being on medications and having ablations, then we would consider transplant. But we don't transplant patients just for chronic atrial fibrillation. Usually they would need to have something else with it, such as heart failure, end-stage heart failure, that we would consider a transplant. Excellent. So I'm gonna also ask you another very controversial question. What is your take on alcohol restrictions? You know, this is really important. We're about to hit the holiday season and New Year's. So I'm interested to hear what you have to say. So with alcohol intake, when it's, so if alcohol intake has been excessive, and that is the reason for the cardiomyopathy, again, because alcohol in excess is a toxin to the heart, then at that point, we really tell patients to abstain. So no alcohol at all. If we know that alcohol was the culprit for causing heart failure or the cardiomyopathy. There's also patients that see us and they have end-stage heart failure and it's not due to alcohol intake. We still ask them not to drink or to limit how much alcohol they're taking, maybe one or two drinks a week, because we know alcohol is toxic to the heart. But again, you have to think of alcohol that it is another source of fluid and whether or not you're on a fluid restriction, you have to watch that. But I really tell my patients, and again, there's not enough data or guidelines to tell us what to tell patients, but I just say limit your alcohol because I know patients usually double what I tell them. So I just say a couple of drinks a week at most for patients that have cardiomyopathy. I'm not sure what you tell your patients, Dr. Page. Same thing, I do the exact same thing. That makes me feel so much better. Again, quality of life. I really think quality of life. Absolutely. And if we have no data to definitively tell us or guidelines to tell us what to tell our patients, then I think it's okay to say a couple of drinks a week is not really gonna cause much harm to the heart at that point. Excellent. All right, we have time for, I would say for one more question. So this is a very, very hot topic right now, and I'd love to hear your opinion on this, okay? And of course, as a cardiologist, you have to also be an oncologist and now a psychiatrist and now an endocrinologist, particularly with this relationship with type two diabetes and heart failure. So what is your take on the use of this new class of the SGLT2 inhibitors in patients with and without diabetes? That's a very interesting question. That is a great question. So the answer is easy. If a patient has any cardiac disease or diagnosis and diabetes, then they should all be on SGLT2 inhibitors because we know that their cardiac benefits are great, whether it's heart failure hospitalizations or just long-term outcomes. And so I actually look at these drugs, the SGLT2 inhibitor class of drugs as cardiac medications because of their quote unquote cardiac side effects or their cardiac benefits. So anytime I see a patient in clinics that has heart failure and diabetes, I usually start the SGLT2 inhibitor myself and just let the endocrinologist or the primary care doctor know that I started them on it. I usually keep them maybe on the metformin that they're on and then add an SGLT2 inhibitor, maybe get rid of one other diabetic medicine again, because I'm trying to reduce the burden of medications, but we do know that SGLT2 inhibitors have lots of benefit. In terms of describing SGLT2 inhibitors in patients without diabetes, hopefully that will be coming in the next heart failure guideline update that's gonna be coming out in 2021. But as of now, I'm not sure that insurance companies will cover SGLT2 inhibitors in patients without diabetes. Although the trials have shown that SGLT2 inhibitors in patients without diabetes do have cardiac benefits, but I'm just not sure that the insurance companies will allow us to prescribe those at this time. But I think in the next set of heart failure guidelines, if the American College of Cardiology, American Heart Association and the Heart Failure Society of America say that SGLT2 inhibitors should be used in patients without diabetes, then it'll be much easier to get these medications for our patients. Oh, you bring up a really good point too. The unfortunate, I know here in Colorado, we're biting at the bit to try to prescribe some of these agents in just patients who have heart failure with reduced ejection fraction without diabetes, but we're having, again, exactly as you mentioned, the stumbling block is the third party payers. My hope is, I'm hoping we'll see that in the new iteration because it does look like there's some robust findings. Is there any particular SGLT2 inhibitor that you kind of use or do you just go based on patient's coverage? Dapagliflozin is the one that I've been using mostly because again, just because of the DAPA-HF study that came out this year. But if the insurance company is not covering it, then I just go for any SGLT2 inhibitor because I think they're all in the same class and hopefully they all have the same benefit. But usually I start with Dapagliflozin and if I can't get that, then I just go to whatever their insurance company is willing to cover for them. Awesome. Well, I wanna thank you so much. It is honestly a pleasure presenting with you today. And again, for those of you who still may have some lingering questions out there, we can follow up by email and we'll do our best to answer your questions. Alrighty. So I do again wanna thank all of our listeners out there today. And I hope that this webinar has provided you with some essential tools and important information that you can use in either with managing your heart failure or caring for a patient with heart failure. But before we end, I do wanna highlight something that's very, very important. And I'm also, and we're both very excited about this, is that the HFSA has now started a new patient membership. And what we are hoping for is that this partnership will be with clinicians and patients and will provide interested patients with the leadership, collaboration and advocacy opportunities that we get as clinicians through the Heart Failure Society of America. And then we wanna provide those benefits to you, our patients. HFSA will follow up with you after the webinar to provide more information if you would like to proceed. And again, this webinar will be available on the HFSA website. And we also have some excellent free webinars on topics. Again, that might be of interest to you. And those include diagnosing and testing, medications and challenges of dealing with multiple, this big burden of medication, activity and diet, the potential for participating in clinical trials, this relationship between heart failure and diabetes that we talked about. And then advanced heart failure. When should patients seek follow up? Now, I would like to highlight too, that we ask that you provide a complete and complete a brief evaluation of the session. We really want to hear your feedback. What is your interest? What also would you like to see HFSA provide in terms of educational material? Now, this evaluation is gonna appear on your screen automatically at the end of this live session and will also be available on the website after the webinar concludes. Again, I want to thank our speaker, Dr. Nazarene Ibrahim, who has again provided such excellent, wonderful information, as well as to you, our listeners and our patients. Again, if you have any questions, we will also try to answer those via your email. Again, thank you so much and everyone have a wonderful day.

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