Welcome, everyone. We're just going to wait for everybody to be entered in, and then we'll begin the webinar. Wonderful. On the behalf of the Heart Failure Society of America and the Education Committee of the Heart Failure Society of America that I chair, I welcome you all this evening to our first installment of Heart Failure Certification Boot Camp. This is an educational experience that we've created for you that's going to take place in three different fragments. This is the first evening, and there'll be two more evenings coming up over the next month. And we're looking forward to sharing with you preparations that will help you prepare to sit for the heart failure certification exam. Next slide, please. So this evening, we're going to be covering prevention and systems of health care, and we're going to be having two speakers with us. First of all, let me introduce myself. I'm Jennifer Cook. I'm the chair of the Education Committee and the chair of the faculty, our program chair for this seminar this evening. And we have two speakers this evening. One is Dr. Franny Modi, who is going to be speaking to us on prevention. And we have Dr. Imo Abong from University of California, Davis, who's going to be speaking to us on systems of health care. And so what we'll do this evening is we'll get started with some audience response questions. So we're going to start by testing your knowledge. After these remarks and introductions, we'll be testing your knowledge, followed by a didactic presentation, and then question and answer on the first session. So without further ado, I would like to turn this over to Dr. Modi, who's going to get us started with the first set of questions. Good luck, everyone. All right. Thank you very much, Jen. So if you could bring up the audience response questions, Cynthia. My talk is, as Dr. Cook said, on prevention. Since the smaller talk, there will be larger ones on systems of care and management in the other seminars. But this is a very important topic. And let's see what people have to say about the first question. So compared to ideal management, when a person has already heart failure with GDMT and non-pharmacologic measures, primary prevention with vigilant core morbidities, such as diabetes control, hypertension control, lifestyle risk factor control, results in saving less, more, the same, or not sure of the number of heart failure deaths in the population. Go ahead and answer that one. What is the value, in terms of lives saved, for preventive heart failure management as opposed to treatment? So, okay. More. Very good. Okay. So the poll's ended. Let's go on to the next one. So when you have vigilant hypertension control per guideline goals, which is one of the main core morbidities that results in heart failure, how much does it prevent in terms of reducing new onset heart failure incidents? How many less people will have heart failure if you control the blood pressure very carefully? 25%, 40%, 50%, or 75%? Okay, that's very good. See there's a lot of equivocation on that one, but still half of them answered at 50%. So let's go on to the last question. Lifestyle risk factors have a robust correlation with reduction. Oops, I can't read the question there because of, okay. With reduction in heart failure incidents, which of these lifestyle factors that have a robust with reduction are which ones? Obesity, tobacco use, respiratory cardiac fitness, obesity, tobacco use, alcohol, and diet, and tobacco use, diet, and vitamin supplements, or none of the above? Which are the ones where intervention of these risk factors results in the most prevention or reduction in incidence of heart failure? Never getting heart failure, in other words. Okay, so there's a 50-50 answer there. Good. So we have something to learn there. There's a lot of distribution of the answers. Good. I think we can go on to the presentation, Anna. Hello, everybody. It actually is protective. So this is what we call the heart. Hello, everybody. My name is Dr. Franny Vagevala-Modi. I'm the Director of the Heart Failure Program at the Greater Los Angeles VA Medical Center and Professor of Medicine at the David Geffen School of Medicine at UCLA. I want to thank the Heart Failure Society of America of putting on this webinar, which is initially organized by the Heart Failure Certification Education Council. And they have assigned it to the Education Committee to put forth this virtual boot camp for heart failure certification. So thank you all for coming to this webinar. I know we all have a common goal, which is optimizing management of heart failure in patients. And I want to thank the program chairs and the faculty for organizing this, especially to Jennifer Cook, who has taken many efforts to put this together along with my other colleagues and also the faculty who along with me and others on the organization chair will be putting together this talk. So let's get started. My talk is actually the first of this webinar, and it's focused on prevention of heart failure, which I prefer not to call heart failure. I call it heart pump dysfunction. And it is a relatively small talk compared to the others on management and treatment, but it's a very important talk because it works towards our common goal of reducing the number of deaths with heart failure in this country. I have no disclosures. And let's start off with the goals that we want to achieve. All of these, the majority of these goals, except for the two and three, which are asterisk are something that I've added on, but they are from the heart failure certification council. So what do they want us to know about prevention of heart failure? They want us to understand the risk factors and co-morbidities that contribute to the development of heart failure. So the incidence of heart failure, age, Chagas disease, hypertension, renal dysfunction, thromboembolism. And then I've added these two goals, which is to know, have knowledge on the hypertension control and how it affects getting new onset heart failure, the incidence of heart failure, preventing heart failure itself, and the knowledge of using SGTL2s in diabetic patients to reduce onset of heart failure. The remainder of the goals, which is to, are more towards preventing hospitalization, not the incidence of heart failure, but hospitalizations. And what I saw from looking at my colleagues' content development is a lot of these are actually covered in their talks. Dr. Ebang, who follows me, will be talking a lot about systems of care, the management and assessment by Dr. Shedavsky will also include a lot of these goals to prevent heart failure hospitalization. So I will not cover many of them to reduce redundancy, but it's more to educate the patient after they're in the hospital about how to prevent themselves from coming back to the hospital, re-hospitalize, educational positive behaviors, recognizing symptoms, enhancing provider and patient communication to prevent readmission and train transitioning heart failure patients and caregivers to self-monitor so they know when to come back into for, to prevent re-hospitalization. So here's the first slide on preventing. So most of my talk would be on preventing the incidence of heart failure. So here's the first and probably most important slide, which is to say how prevention will actually result in more lives saved with respect to reducing the number of deaths from heart failure in the world. And I think the best way to summarize it is the old adage that says an ounce of prevention is worth a pound of cure. So prevention is actually more important than cure and prevention would be looking at the incidence of risk factors and how to modify them. So you don't get heart failure and the cure would of course be GDMT and all the other ways that we treat heart failure once we've gotten it. And here's the number or numerical way of explaining that. If you think about six and a half million people having heart failure and about 960,000 develop new heart failure. So the incidence of heart failure every year, there's about a 50% reduction in heart failure incidence if you control blood pressure well. So that means instead of 960,000 patients getting heart failure, it would only be 480. So the whole pie of number of people with heart failure in the country symptomatic would be shrunk into half if we used all the methods to prevent heart failure rather than treating it after we've got it. And if you look at what happens after people have got it, if you look at the GDMT, they'll usually it's about a 30 to 50% reduction in mortality. So instead of 30 to 50% of 960,000 patients dying, it will be 30 to 50% of 480. So the number of lives lost due to heart failure would be reduced by quite a lot. And this again is breaking down what GDMT does depending on age. If you're less than 65, it's a lot better prognosis, 80% dying are alive at five years. And if you're over 75, 50% are alive at five years. But as you can see, if the number of percentage, the absolute numerator is reduced, you would be saving a lot more lives dying from heart failure. So let's go back to the basics that came out with these guidelines of classification of heart failure. So we knew which subset of patients we're trying to treat in prevention of heart failure. So of course we have stage A, which is people at risk for heart failure. So they have the core mobilities and risk factors, lifestyle risk factors that put them at risk of developing what we call stage B, where there's a cardiomyopathy. There's actually structural heart disease. These patients just don't have signs and symptoms of heart failure. And then when we talk about 50% mortality at five years, we're talking about people who have symptomatic heart failure, the ones that you treat in the heart failure clinic, which is stage C, and then the advanced heart failure, which is stage D in heart failure clinic. So this whole talk is geared towards this stage A of people who are at risk for heart failure and whether what we want to do is prevent them from becoming stage B. That's what this talk is geared towards, to see how we can keep them here in stage A. So what are the recommendations by the last guidelines? What are we supposed to do for patients who are in stage A? And that's essentially what we'll be going over. What's the evidence that this is what we need to be doing? And if for people who are at risk for heart failure, patients with hypertension, control their blood pressure, patients with diabetes, give them SGTL2-1 inhibitors, which as I said, is a class one indication. So the level of evidence in terms of reducing lives saved of dying of heart failure is much, much less with SGTL2s. Patients with CBD, optimal management, patients who have cardiotoxins, multidisciplinary evaluation, first degree relative, genetic counseling. And then there's a consideration of perhaps routinely and periodically getting biomarkers like BNP to make sure that they haven't gotten into stage B, which is on the right side of the screen here. And then the multiple variable scores to make sure that they haven't reached it. So this is the outline. We're going to be talking first about preventing the heart failure incidence or getting new onset heart failure. And then just the last slide will be on preventing of heart failure hospitalizations, because it'll be covered by my colleagues and co-faculty with what to do once they've got heart failure to prevent re-hospitalization. So in stage A, these are the three disease processes or co-morbidities that are people who are prone to becoming stage B. Atherosclerotic heart disease, people who have CAD, CVA, peripheral artery disease, people who have hypertension are the most likely to go on to have heart failure stage B, and then patients with diabetes, because they're at more risk for having heart attacks and then going on to develop ischemic cardiomyopathy. So let's first focus on the patients who have core morbidities that can result in stage B, which is getting LV and RV damage or structural heart disease. What's the data that we have on those patients? And who are they first? As I mentioned, it was patients with hypertension, diabetes. The goal to keep these people from going into stage B would be controlling their blood pressure to less than 130 over 80, diabetes, bringing the A1C down to less than 7.5. And mainly that occurs by reducing CAD progression, acute MI, going on to ischemic cardiomyopathy. What else do we do for patients with diabetes, SGTL2, we'll look at the data on that. The data on GLP-1 antagonists in diabetics to reduce heart failure incidence is a little bit mixed. There is a suggestion that actually once they get heart failure, that actually GLP-1s, it's possible that maybe it could even be harmful in terms of worsening the LV function. Is there any data on patients with hyperlipidemia on statin use? And the answer is no. We don't have any data that using statins in patients who need it for hyperlipidemia will reduce their chances of having a new onset heart failure stage B. And we see that from the GCHF trial and the Corona trial, where there was no preventive benefit and possibly weak evidence in patients with heart failure that it may help the mortality. Cardiotoxins, of course, we have to be mindful of that in terms of preventing LV dysfunction. And we're talking about adramycin, a very common chemotherapy agent that we've used for breast cancer and a lot of other cancers. And now, of course, there's new immune checkpoint inhibitors, the immunologics, which can cause myocarditis and cause stage B structural LV dysfunction. And then you have to be mindful of other comorbidities that you are treating or the primary care is treating that you want to make sure they don't go on to stage B and developing LV dysfunction, which is things like valvular heart disease. And people have aortic regurge, mitral regurge, aortic stenosis, tricuspid regurge to prevent them from having LV and RV failure. We're talking about infectious diseases like Chagas disease, parasite, bacterial, viral, like HIV, fungal disease to make sure it doesn't result in development of LV dysfunction. So when we talk about patients in stage A, which is the worst one to have that increases their risk of going on to stage B? And the answer is hypertension. As you can see here is the most common risk factor that results in people going on to stage B, developing structural myocardial dysfunction, and then, of course, increasing the risk of getting becoming symptomatic, which is stage C. So you can see that hypertension almost double that of the other risk factors that we mentioned that could put them into heart failure. And what is the data that we have that hypertension reduces developing stage B heart failure with getting structural heart disease? And this is all data that comes from the early 1990s that show that with hypertension treatment, and in our case, it would be 130 over 80, you can see that there's a 52% reduction in going on to develop new onset heart failure. There is a reduction of stroke by controlling their blood pressure, CV deaths, et cetera. But it really is overshadowed mainly by reducing stroke rate. I mean, reducing heart failure rate. And then let's go on to the what's the evidence and strong data that we have of treating diabetic patients with SGTL2. And I will give one of the two big, large randomized trials that have shown this, which is what makes it a class one, level one indication. That means it must be used. And these are patients with diabetes. And, you know, these studies were actually done to see what would happen to diabetic patients who were given SGTL2, ampaglifazone in the AMPA-REG trial, and dapaglifazone in the DECLARE trial to see what it would do to reduce fatal MI, you know, CAD type of deaths and atlas carotid deaths. But serendipitously, they found that it reduced heart failure hospitalization much more than even coronary artery disease related deaths in patients who are diabetics. As you can see here, it's a very, very strong signal to show that it reduces it. So it actually does something to the myocardial muscle in terms of reducing heart failure incidents. But despite very good treatment of heart failure, comorbidities like hypertension and diabetes, they still find that there's a lot of new onset heart failure. Most of it is also non-ischemic cardiomyopathy. And so they've been studying to look to see if there's lifestyle risk factors that result in some of these comorbidities that treating them would end up resulting in reduced heart failure hospitalizations. So these are the risk factors that have been studied that we'll be going over to look at the data. So obesity, alcohol consumption, obviously a lifestyle risk factor because we do know that alcohol is a cardiotoxin and can result in alcohol induced cardiomyopathy. So we won't discuss that much more. But limiting alcohol consumption certainly results in less cardiomyopathy stage B. Tobacco use, substance use, very well known that cocaine and methamphetamine are cardiotoxins and can result in cardiomyopathy. We'll talk about physical activity as a cardiorespiratory fitness as a way of preventing cardiomyopathy or stage B. And then we'll talk about diet and vitamin supplements. Diet, of course, in terms of reducing the risk of diabetes and CAD prevention to reduce ischemic cardiomyopathy as a way of doing it too. And then we'll talk about some of the vitamin supplements, which is thiamine, CoQ10, carnitine, and sodium restriction. So the three that I will be focusing on are obesity, physical activity, and diet and vitamin supplements in terms of how they prevent the incidence of new onset heart failure. So obesity is probably the most studied and probably has the best data in terms of prevention of heart failure. We have multiple large studies that show that obesity is related to incidence of heart failure. There is a dose-dependent relationship increasing body mass index, which supports a causal role that the obesity itself results in a cardiotoxin effect in stage B heart failure. Avoiding obesity, what they've shown, mostly in the cardiovascular risk studies, results in a markedly lower risk factor if it's combined with other things like modest alcohol intake, no smoking. Keeping the BMI below 30, so less in the overweight, but not obesity, for over 20 years has shown a 30% reduction in ever getting heart failure and then going on to get the best morbidity with it. Large amounts of sustained weight loss through bariatric surgery has also resulted in reduction in LV mass and new cases of heart failure. But obesity, with respect to heart failure, it's a nuanced thing and there's a thing called obesity paradox that we have to be aware of, where being overweight and reducing weight prevents heart failure. But if you are overweight and have stage C heart failure or D, it actually is protective. So this is what we call the heart failure paradox. Not quite well understood, but it is certainly something that we've seen over and over again. And certainly we know that once you've developed stage C and D heart failure, losing a lot of weight unintentionally, probably what we call cardiac cachexia is related with the worst prognosis. In terms of treating obesity and exercise with hypocholeric diet has shown a benefit in terms of HEF-PEF patients with stage C, that it improves the exercise capacity and stiffness of the heart. So it's possible that it could be also part of treatment in terms of preventing the worsening of HEF-PEF. And so what we can conclude from it, the maintenance of normal body weight through the adult life is a strongly positive risk factor for against heart failure and bariatric surgery in obese patients has been shown to reduce the incidence of heart failure. How does the obesity impact on a new onset heart failure? Multiple mechanisms, mainly inflammation and myocardial injury. Hypertension is reduced also when you impact on obesity, resulting in less LV mass, et cetera. So there probably is a direct effect on myocardial function. Physical activity is also something that has been shown to improve LV function and reduce the risk of developing new onset heart failure or stage B, where they don't have the symptoms, but myocardial damage. And most of this data comes from the woman's health study, the physician's study that showed that physical inactivity and cardiorespiratory are independent risk factors for development of heart failure or even stage B where they have myocardial damage. So if you are unfit or less than eight metabolic equivalents, what we call deconditioned, there is definitely an impact on lowering the risk of what age you get the heart failure. They also may be an upper limit though. So exercising is good, but running marathons is not going to be more protective of preventing heart failure. So there's dose dependent, there's an upper limit. There is also some data that in patients who have heart failure like HEF-BEF, that improvement of exercise and fitness does over two years, if it's sustained, does reduce cardiac stiffness. So it is possible that this is going to improve HEF-BEF. What about diet? Well, in the physician's health study and similar studies done at Elseplace, there is data to show that a diet made of fruit and vegetables does result in improved myocardial function and having red meat or diets high in phosphatidylcholine can result in increased TMAO and result in more CAD infarction and heart failure. And in terms of the diet, if you have a DASH diet, which was initially, of course, made for hypertension, we can see that there's actually a 26% reduction in heart failure incidence. So what's the conclusion we can make about diet in terms of reducing heart failure incidence? Population-based samples and limited data from randomized controlled diets. Dietary studies are always very difficult to do in terms of randomized control because it's self-reported diet intake. We show that there's a modest benefit in terms of reducing heart failure incidence and healthful eating patterns does reduce with Mediterranean diet, whole grain does reduce the interest of heart failure development. Let me just quickly run through vitamins and supplements. And all of these actually, CoQ10, L-carnitine, no data to show benefit. L-coenzyme A does help in terms of if you have heart failure to improve function, but there's no data on vitamin D or any of these to show that it reduces the onset of heart failure. Maybe a very weak signal of multivitamins in the strong HF trial to show that there's reduction in incidence of heart failure. And I won't belabor this point. I've already talked about what the mechanism is, but these diet and lifestyle habits probably go on to result in inflammation and then in the core morbidities that result in cardiac remodeling. So this is how the mechanism is. And then finally, this last slide is to show how to prevent hospitalizations. And I will just go over what my colleagues will be focusing on to prevent rehospitalization and where they will show you the evidence on it, on GDMT to prevent rehospitalization, educating patients on compliant behaviors like diet adherence, medication, flexible self-teaching of diuretics to reduce rehospitalization, systems of care, which Dr. Yibong will be discussing following me, and then educating patients and caregivers on discussing heart failure, recognizing heart failure symptoms, getting early access to being treated by the provider to reduce the risk of being rehospitalized. So that's the end of my talk. And thank you very much for your attention. And we will go on to the Q&A session. Oh, one other thing that they will hopefully be discussing in terms of preventing rehospitalization, which is cardiomyems and sensors of fluid retention, which also reduce hospitalization. The references are listed here that you will be getting from there. So thank you very much. Well, thank you so much, Dr. Modi. This was a wonderful presentation, and I'm really looking forward to conversation now with our Q&A session. So I welcome our participants who are live with us this evening to enter questions into the Q&A. And I believe that you wanted to start by going back through the questions again. Yes. I just thought it'd be good to review those three questions, especially when they were equivocation on at least the last one, to see how people think after the talk on what the answers are. So let's look at the first one, which is compared to ideal management after a person has had heart failure, including GDMT and non-pharmacological measures. Does primary prevention using core mobility control of hypertension, diabetes, and lifestyle risk factors result in saving the number of heart failure deaths in this country? Would it be more or less or the same compared to management after you've had heart failure? Well, I see we have the participants voting here. We have about 76% who have participated. Okay. Let's go ahead and end that poll and share the results. Okay. Very good. And that is the answer. It just goes to show the importance of taking preventive measures in terms of reducing life saved from heart failure deaths. Okay. Let's move on to the next question, which is, of all the core mobilities that can result in development of heart failure, vigilant hypertension control is probably the most important. And what is the number of a reduction in heart failure cases or new onset heart failure from strict blood pressure control, 25, 40, 50, or 75%? So we had quite a spread last time. I know that the participants weren't able to see the results, although the speakers here were able to see the results. We have 72% of the participants have voted right now. So we'll just give them a couple more moments to put in their answers. Very good. Very good. So I think most people got it right this time. I think there was, as you said, it was 50% who answered 50%, but this time it's come up to 90%. So that's really good. Okay. Let's look at the last question, which is, of all the lifestyle and risk factors that we've talked about, which are the ones that are known to reduce the incidence of heart failure? Obesity, tobacco, and cardiorespiratory fitness, obesity, tobacco use, alcohol, and diet, tobacco, diet, and vitamin supplements, or none of the above? Hmm. Looks like we're going to be able to discuss this one. We had a split the first time it was answered, and we're splitting again here. Okay. So now everyone can see the results. So Charmaine, could you explain this to us? Tell us about this question and drive this point home for us, please. Right. So I think that the really strong data where we show a reduction in hazard ratio of development is the strongest with obesity. And then, of course, it is also with tobacco use. With alcohol, it's a little bit mixed because most of the studies have such large differences in terms of alcohol consumption that they've correlated it with. So we haven't seen that much with alcohol and diet, as I mentioned. We do see a good signal with things like eating fruits and vegetables, but we really haven't shown a very, very strong reduction in diet other than perhaps the DASH diet. And they think that's mainly through reduction in hypertension, but not direct obesity, not direct reduction in incidence. So the three that have shown like a dose-dependent thing where there's change in this risk factor, therefore change in incidence are obesity, as I mentioned, about a 30% reduction, tobacco use, which I didn't discuss, but there's so much data on it overwhelmingly, and cardiorespiratory fitness, which I said there was a dose-dependent effect, but there was an upper limit to in terms of direct correlation with reduction in incidence of heart failure. So the answer is A. Okay. I think this is so fascinating because I'm thinking of myself at the bedside. So talking to those patients who are either newly diagnosed with heart failure or maybe doing some counseling who have a family history of heart failure, and how do we address obesity? The obesity paradox is something that has really puzzled me and I have found to be fascinated with for many years. What would your recommendation be for someone who is obese that's in front of you in clinic? With heart failure. With heart failure, I guess, or either way, you can answer it either way that you like. But it seems to me like as I am moving forward and getting more sophisticated, I'm really focusing on the cardiorespiratory fitness because we know that having the capability or having that soulmate exercise that keeps people moving is so much more impactful than the weight loss because of the obesity paradox. Right. Yeah. Once you see the patient with heart failure, the data is that we don't know that telling them to lose weight is going to be helpful. That's what the paradox is all about. And in fact, if they lose too much weight, we know that it's a bad sign, probably because it reflects cardiac cortex and more advanced heart failure. But the data on preventing obesity in reducing obesity to prevent heart failure is mainly with the primary care doctor. So it's before you and I see the patient, that's where it is the most benefit from it. So it is really more of a societal problem, primary care that shows that there's benefit from it. And as you said, with the cardiorespiratory, there is benefit even in people with heart failure and before they get heart failure, that it's helpful. So probably for that, I think even when you and I see the patient with heart failure, it would be helpful to focus on because there's very strong data. This very strong data is mainly on obesity, alcohol, as I said, I mean, tobacco and cardiorespiratory fitness. Thank you for that. So we have some comments and questions in the chat. So the first is, will we have access to re-listen to the lectures and we have access to the slides? Yes. Everyone who's enrolled in this seminar will have access to play this back, you know, so that you can experience it live these few nights and then be able to study from it as well in the future. The next question is, so this is from Diane. So is that why there is mixed data on GLP-1 in those with CHF going back to the paradox? No, I don't think it's from the paradox. They just think that the molecular, first, we don't understand how SGTL-2 works, right? Because the mechanism of action is, you know, some people thought it was a very smart diuretic first. They were getting osmotic diuresis with the glucose. Then they thought it was a sodium potassium ATPase. Then they think it's something else. So we don't really know what the benefit is from SGTL-2 in terms of reducing heart failure, but GLP works in a different way. And I think it just doesn't have the same cardio toxin, the cardio, you know, the mechanism of what exactly does to the myosin that SGTL-2 does. All right. Another question. This is from Carol. Let me just go back to that, you know, because it looks like GLP-1s may be helpful in preventing heart failure for the person who's in stage A. That could be through reducing weight. But, you know, as I said, we haven't seen that same benefit of losing weight once they've developed stage C and D. So it makes sense then that the GLP-1s won't be helpful. And in fact, there's some data that they may be a little bit of harm. So, and we don't know what the mechanism of that is, how that comes about, but it's not necessarily from losing weight, but possibly the paradox also. Okay. Again, about the GLP-1s, question from Asim, is a slide about GLP-1 said GLP-1 antagonist, should it be agonist? Likely a typo. Oh, right. Sorry about that. Yeah. And so from Carol, could you provide some examples how you would counsel a patient about exercise, maybe after diagnosis, particularly in the obese HEF-PEF population? I'm sorry, I didn't, I didn't see the question. Could you say that again? Sure. I'll read it again. This is from Carol. It says, could you provide some examples on how you'd counsel a patient about exercise, maybe after diagnosis, particularly those in obese HEF-PEF population? Right. So I think it's not very different from what we would for people with coronary artery disease. You always start off by telling them that you have to start slowly and keep in mind that the fitness is just, you know, because you start off at different levels of fitness. What I recommend, because I'm also a preventive cardiologist, is to say that we talk about 30 minutes, you know, every day for seven days a week, if possible, and you walk fast enough. So it doesn't involve any running, getting on any Peloton bike or anything like that. It just means walking enough and at a pace where you feel a little short of breath and have difficulty having conversation. That's when you know that you're walking fast enough because that's walking fast enough for you. So that's how you individualize at what pace you go. And if you do just that for five, for 30 minutes, five days a week, optimally seven days a week, but minimum five days a week, that is the best way to get cardiorespiratory fitness. That is shown to be helpful for MACE, you know, in terms of athletic events and also cardiorespiratory for heart failure. Carol, I also have had some success with talking to my patients about cardiorespiratory fitness and giving them permission to ditch the scale, mainly because of this obesity paradox and that so many people are exercising to lose weight and to see the number on the scale go down, but the benefit really comes from the behavior of the exercise. And so a lot of our patients will quit because they're not losing weight, but they're really seeing a benefit from the cardiorespiratory fitness. So this is something I've started to do as I've become learning more about obesity and heart failure saying, you know, it's okay to ditch the scale, don't exercise to lose weight, exercise to find your soulmate exercise that you love to do that's going to help your heart. Right. Well, if you get on a treadmill and you see how many calories you lose, you'd be very disappointed because it probably won't even be one cookie. So exercise is definitely not to lose weight, perhaps for maintenance of weight. Unfortunately, when you have heart failure, you can't ditch the scale because you won't know if you're getting edema and fluid retention. So you just tell them that you're not exercising to lose weight, you're exercising to get fit, which will help you with your heart failure and live longer with your heart failure. That's wonderful. Okay. Well, in interest of time, unfortunately, we need to move on, but I'm so glad that everyone participated in the question and answer. And for those of you that we didn't get a chance to, Dr. Modi, if you could get into the chat while Dr. Yibong is speaking and maybe respond in the chat. And we're going to turn it over to Dr. Yibong who is going to take us through her questions. Awesome. Excellent. Thank you so much, Jen, first for this opportunity and I'm really excited to see your response to the questions. And after that excellent presentation by Dr. Freni, I think I learned a couple of tips myself. So let's move on to the first question. Which of the following correctly provides the list of heart failure core measures as initially proposed by the Joint Commission. So this is a single choice answer. A is LVEF assessment, discharge instructions, as well as use of beta blockers, and use of ACE inhibitors and ANIs. The whole answer is not shown there. B is discharge instructions, LVEF assessments, smoking cessation, and use of ACE inhibitors and ANIs. C is smoking cessation, multidisciplinary care coordination, use of beta blockers, and use of ACE inhibitors and ANIs. And D is LVEF assessment, smoking cessation, use of beta blockers, and use of ACE inhibitors and ANIs. Excellent. I like this. This is a very variable. So I guess we'll see what the answer is. Let's move on to the next question, please. Next question. All right. So question number two, the following heart failure measure achieved an implementation rate of greater than 97% and was retired from the 2020 heart failure clinical performance measures. A, post-discharge appointment for heart failure in the inpatient. B, LVEF assessment in the inpatient. C, exercise training or cardiac rehabilitation referral in the inpatient. D, LVEF assessment in the outpatient. E, symptom and activity assessment in the outpatient. And E, exercise training or cardiac rehabilitation referral in the outpatient. Excellent. So a lot of varied responses still. Very interesting. And Cynthia, I think we can move on to the third question once we're done with the poll. All right, this is question three. What percentage of early heart failure readmissions are due to poor transition of care practices? A, 10%. B, 20%. C, 30%. D, 40%. E, 50%. So once we're done with the poll, we can move on to the fourth and final question. Awesome. So the final question, Mr. Black is a 44 year old African American man with no significant past medical history, who has been newly diagnosed with heart failure. He does not own a car and does not have health insurance. He lives alone and works part time as a janitor in a community high school. Which of the following is least likely to affect his heart failure outcome? A, lack of social support. B, inadequate transportation. C, poor health care access. D, family history of heart failure. And E, low literacy levels. Awesome. There's some variation here as well, which gives a great opportunity to move into the lecture once we're done with the polls. There will be a lot to discuss when we get back to the audience response. Welcome to the Heart Failure Certification Virtual Bootcamp. My name is Imao Ibao and I'll be presenting the session on systems of healthcare and heart failure. I am an advanced heart failure and heart transplant cardiologist at the University of California, Davis. These are our program chairs and program faculty. I have no disclosures relevant to the content of this presentation. In this session, we will discuss the heart failure core measures, performance measures, and quality measures. What are they and how are they different? Transitional care in heart failure and pre-discharge education, social determinants and barriers to heart failure care, team-based care in heart failure, including palliative care, heart failure education for providers, and administrative roles and policies for heart failure. The heart failure core measures, as initially proposed by the Joint Commission, consisted of four components. One, the use of an angiotensin-converting enzyme inhibitor, or an angiotensin-2 receptor blocker for left ventricular systolic dysfunction. This measure was associated with a 20% reduction in mortality. Two, left ventricular function assessment. Three, smoking cessation counseling, which has been associated with an improvement in quality of life. And D, discharge instructions consisting of activity level, diet, discharge medications, follow-up appointment, and weight monitoring. This measure has been associated with a 10% reduction in mortality and 25% reduction in hospital readmissions. How are the heart failure performance measures different from quality measures? The goal of heart failure performance measures are to improve quality of life by assessing the implementation of guidelines in eligible patients. Performance data are publicly reported and pay-for-performance programs are in place to promote implementation in clinical practice. All the performance measures are supported by evidence and have high value, and sometimes include a treatment measure paired with a safety measure. Quality measures, on the other hand, are evidence that are not ready for public reporting or pay-for-performance, but are useful for quality improvement. The 2020 AHA and ACC update on the heart failure performance measures consists of 13 components. Performance measures one to three occur in the outpatient setting and include left ventricular ejection fraction assessment, symptom and activity assessment, and symptom management. Performance measures four, five, and six occur in both outpatient and inpatient setting, and include use of beta therapies for heart failure with reduced ejection fraction, use of ACE inhibitors or ARBs or ARNIs for treatment of heart failure with reduced ejection fraction, and ARNI therapy for heart failure with reduced ejection fraction. Performance measures seven and eight occur in the outpatient setting and involve the dose of beta blocker therapy for heart failure with reduced ejection fraction, and the dose of ACE inhibitors, ARBs, or ARNI therapy for heart failure with reduced ejection fraction. Performance measures nine, 10, and 11 occur in both outpatient and inpatient settings, and include use of MRA therapy for heart failure with reduced ejection fraction, laboratory monitoring in new MRA therapy, and use of hydralazine with isosorbide dinitrate therapy for heart failure with reduced ejection in Black or African American individuals. Performance measure 12 and 13 involves counseling regarding ICD implantation or CRT implantation for patients with HFREF who are on guideline directed medical therapy and are caused in the outpatient setting. These performance measures occur across various domains such as diagnosis, treatment, as well as monitoring for heart failure. There are also quality measures. There are four quality measures, which include patient self-care education, measurement of patient reported outcome health status, sustained or improved health status in heart failure, and post-discharge appointment for patients with heart failure, which occur in both the outpatient and inpatient settings. There's also a structural measure which involves participation in heart failure registries. This occurs both in the outpatient and inpatient settings. And finally, there are rehabilitation performance measures related to heart failure and involve SSI screening referral for heart failure from the inpatient setting as well as from the outpatient settings. These performance measurements are supported in heart failure guidelines, and they have a class one level of recommendation, which states that performance measures should be based on professionally developed clinical practice guidelines with the goal of improving quality of care for patients with heart failure. Additionally, participation in quality improvement programs, including patient registries that provide benchmark feedback on nationally endorsed practice guidelines, can also be beneficial in quality of care for patients in heart failure. And this particular recommendation has a class, has a 2A level of evidence. Transitional care is very important in heart failure and includes all those actions that promote care coordination and continuity as patients transfer between healthcare settings or providers. The daily risk of readmission and death in the month following hospitalization for heart failure is 0.7% and 0.2% respectively. And up to 40% of early heart failure readmissions are related to suboptimal transitional care practices. Some of these transitional care practices include self care education, as well as an early provider follow up. The discharge or transitional care summary should incorporate information around the hospital costs, plan therapies, and monitorings in the outpatient, as well as follow up for related comorbidities and advanced care planning. The hospital costs should involve information on the reason for admission, sentinel symptoms, congestion status, including objective assessment of volume status, admission and discharge weight, diuretic agent dosing, rescue diuretic dosing and unexpected events. Plan therapies and monitoring includes plans for GDMT optimization, plans to monitor electrolytes and kidney function, as well as follow up for pending or planned diagnostic testing. Follow up related to comorbidities, such as chronic kidney disease, sleep disordered breathing, diabetes, atrial fibrillation, coronary artery disease, obesity, and anemia should also be clearly documented. And finally, advanced care planning, which should provide information on prognostic assessment, as well as palliative care referral should be included in the transitional care summary. This is an interesting study by Van Spel et al, which evaluated the comparative effectiveness of transitional care models in reducing all cost mortality in patients who have been hospitalized with heart failure. In this study, Van Spel and his colleagues showed that disease management clinics as well as nurse home visits had the most significant effects in reducing all cost mortality amongst patients that have been hospitalized for heart failure. In the same study, Van Spel and his colleagues evaluated the comparative effectiveness of transitional care models in reducing all cost readmissions after hospitalization for heart failure. In this study, they found that in addition to disease management clinics and nurse home visits, nurse case management was also effective in reducing all cost readmission after hospitalization for heart failure. Pre-discharge education is an important component of the of the transitional care summary. The proportion of patients that were dead or re-hospitalized was significantly reduced among patients that had received pre-discharge education, as is shown in the figure on the left. In the figure on the right, the cumulative event-free survival from heart failure-related mortality or hospitalization, the survival was greatly higher amongst patients that had received pre-discharge education when compared to those who did not receive pre-discharge education. Heart failure discharge education should address several factors, including existing barriers to heart failure treatment, a comprehensive review of patient medications, and self-care education, which should occur in both the inpatient and outpatient setting. The discharge education process should assess the patient's readiness to learn and adopt various teaching methods. The education process should engage caregivers, both in the outpatient and inpatient, as well as other members of the healthcare team. Additionally, the discharge education should optimize use of written materials, emphasize self-care, employ the teach-back method, and assess patient resources, both in the outpatient and inpatient, with clear instructions on appropriate referral to disease management programs, as well as smooth transitions of care. Education is necessary for heart failure providers. In a systematic review by Chi et al., which involved 15 studies and 1,644 nurses on self-care knowledge, most of the studies, 13 of the 15, used the nurses' knowledge on heart failure education principles to measure the mean score of knowledge on heart failure self-care. The overall mean and standard deviation score of the nurses' knowledge was considered unsatisfactory at baseline, with a mean that ranged from 12.1 to 17.3, and a standard deviation that ranged from 1.4 to 2.7, across 20 dichotomous questions in the nurses' knowledge on heart failure education principles. It's important to note that a minimum score of 17 to 18 is considered as having satisfactory knowledge on heart failure self-care education. In this study, Chi found out that the use of heart failure educational interventions had the ability to significantly increase the nurses' knowledge in heart failure self-care education. Consequently, continuous nursing education and referral to standard evidence guidelines on heart failure management should be introduced in the healthcare setting. Social determinants of health is also an interesting and newer concept that is important in the management of several chronic diseases, such as heart failure. They are non-medical factors that influence health outcomes and cause health inequity between and within countries, and unfavorable social determinants of health have been shown to adversely affect heart failure outcomes and mortality, and should be routinely assessed in heart failure care, both in the inpatient and outpatient. The areas of focus should be around how to improve measurement of social determinants of health, deepen understanding, and develop actions to mitigate the effects of social determinants of health, including improving daily living conditions and tackling inequalities in healthcare. Social determinants of health could involve upstream pathways, midstream determinants, and downstream determinants, as shown in the slide, and they revolve around economic stability, the neighborhood environment, education attainment, food availability, community, and the social context, including the social support, as well as the healthcare system. The upstream factors include the upstream factors include income, employment, poverty, housing, insecurity, housing, schools, crime in the environment, psychosocial environment, as well as early childhood education, high school, college education, and health literacy, food insecurity, food deserts, access to healthy foods, social support, social networks, social cohesion and engagement, discrimination, as well as access, cost, and quality of healthcare. The midstream factors include psychosocial stress, physical stress, physical inactivity, unsafe or unhealthy living conditions, unhealthy behavior, such as smoking and excessive alcohol use, unhealthy diet, which is a diet that is low in fruits, vegetables, and fresh food, but increased in processed food, red meat, salt, and saturated fats, race and racism, poor community support system, lack of quality and timely healthcare, and implicit bias. This leads to downstream factors such as hypertension, high cholesterol, diabetes, obesity, which are all heart failure risk factors. Now, heart failure management requires a team approach, which should consist of healthcare providers with diverse clinical skill set. This includes advanced heart failure physicians, general cardiologists, other cardiologists specialists, such as electrophysiologists, interventionalists, cardiac imaging, structural heart cardiologists, geriatrics, co-morbidity specialist, such as a pulmonologist, a nephrologist, palliative care, advanced practice professionals, including nursing practitioners, as well as physician assistants, specialty pharmacy, social work, nursing, as well as home healthcare. And effective management of patients requires intense collaboration and efficient communication between heart failure team members. Palliative care, for instance, should be initiated in tandem with heart failure management and should be focused on controlling pain and other symptoms such as depression and anxiety, assisting with medical decision making and advanced care planning, improving access to care and reducing emotional distress and burden to both the patient and the family, as well as coordination of care across the patient's care team. With the goal of improving the quality of life for both the patient as well as the caregiver. Now, when patients progress to advanced disease, palliative care becomes more specialized to involve more complex support, including initiation of hospice care. Multidisciplinary programs are important for heart failure outcomes. In a systematic review by McAlister et al, which looked at 29 randomized trials, there was a 27% reduction in heart failure hospitalization rates, as well as a 43% reduction in the total number of heart failure hospitalization that was achieved with use of multidisciplinary program. Now, specialized programs that make use of follow up by multidisciplinary heart failure team is equally effective and has been shown to be associated with the reduction in all cost mortality by approximately 25% and a reduction in all cost hospitalizations by 20%. Prior studies have shown that enhanced patient self care follow up monitoring by specialized trained staff, as well as access to specialized heart failure clinics, appear to be the most efficacious interventions in multidisciplinary heart failure programs. Finally, for effective practice or treatment or implementation of heart failure program, it's important to initiate policies and protocols to standardize the management of heart failure. It has been shown extensively by prior studies that development, implementation and maintenance of critical pathways with evidence-based recommendation improves the quality and consistency of heart failure care, leading to reductions in hospital mortality, length of hospitalization, as well as better post discharge outcomes. These programs, policies and protocols for heart failure treatment in institutions should incorporate standardized assessment of patient-reported health status using validated questionnaires, such as the Cancer City Cardiomyopathy Questionnaire. Additionally, participation in programs like Get With The Guidelines, which is an in-hospital program for improving care, promotes consistent adherence to scientific treatment guidelines. Thank you for your patience and time. These are my references. I look forward to receiving them. Okay, so welcome back and I'm eager to see what your responses are to the questions. So, Cynthia, could we pull up the questions again, please? Okay, so question one, which of the following correctly provides the list of heart failure core measures as initially proposed by the Joint Commission? So we'll wait for the poll to be done and see what your responses are this time. As the responses are still coming in, I do want to remind everybody that the presentations and the slides will be available after tonight's session and after the series is completed in the Learning Center on the Heart Failure Society of America website, and the link will be provided to everyone as well. Okay, I think the polls are still going on. Still very varied, so perhaps I did not stress this enough. So I am going to go on. I think the poll is done. Jen? Yeah, so we have the responses. So the majority of people answered B. So what is the correct answer? The correct answer is actually B, but I'm concerned that the responses are still very varied. So this question was on the first slide that we presented. So the initial four core measures as proposed by the Joint Commission, this was in 2013, I believe, consisted of discharge instructions, left ventricle ejection infraction assessment, smoking cessation, as well as use of ACE inhibitors and anise. So beta blockers were not part of that, even though we know that it's very important. Multidisciplinary care coordination was also not part of that. So the correct answer, you're absolutely right, is B. I think that's really great to have an opportunity to drive this point home. I think that some of the people in my program get confused about the Joint Commission versus Get With The Guidelines, because there are different programs that are subject to both guidelines. And so I think that maybe that's a reason why we had a spread here. Okay, excellent. Yeah, and I mean, actually, there's an excellent article by the HACC, updating the 2020 heart failure performance measures. There's a lot of information on this. Let's move on to the next question, please. Okay, so question two, the following heart failure measure achieved an implementation rate of greater than 97% and was retired from the 2020 heart failure clinical performance measures that we just referenced. A, post discharge appointment for heart failure in the inpatient. B, left ventricle ejection fraction assessment in the inpatient. C, exercise training or cardiac rehabilitation in the inpatient. D, left ventricle ejection fraction assessment in the outpatient. And E, symptom and activity assessment in the outpatient. So we'll wait for the poll to get done. A few more seconds. Excellent. I think a poll should be. Am I still running? Yeah, we can go ahead and end the poll. All right. Sure. There we go. Excellent. So, so the most people got this one right. And I'm happy more people got ejection fraction in 97. Almost zero in 2020 heart failure measures. Next question, please. Okay, so the next question, what percentage of early heart failure readmissions are due to poor transition of care practices? A, 10%. B, 20%. C, 30%. D, 40%. And E, 50%. And the poll is still running. We have more people voting this time. Less shy on this question. Yeah, yeah. It's really, it's really interesting. 0.7% of, I think the poll is done. So yeah, most people got the answer right. I think this was a clear line in the presentation. So 40% of early heart failure readmissions can be prevented by good transitional care practices. So you can see that. I think we also kind of mentioned in the slide, 0.7% of re-hospitalizations as well as 0.2% of deaths were actually related to poor transitional care practices. So a formal transitional care is really necessary for you to prevent heart failure readmissions. Let's move over to the final question. So Mr. Black is a 44 year old African American male with no significant past medical history, who has been newly diagnosed with heart failure. He does not own a car and does not have health insurance. He lives alone and works part-time as a janitor in a community high school. Which of the following is least likely to affect his heart failure outcome? A, lack of social support. B, inadequate transportation. C, poor healthcare access. D, family history of heart failure. And I think E was low literacy levels. Okay, so the poll is running. And I think the poll is done. We have one minute. So excellent. So a lot of, I mean, almost everybody got this right, family history of heart failure. So a lot of evidence has shown that social determinants of health and, you know, in the slide that I presented on social determinants of health, they are factors that are, you know, at the upstream down factors that, you know, factors that are intermediate and those that are downstream factors. And, you know, genetic factors, etc. don't really account. If these patients are unable to, you know, come to the clinic, if they don't have the transportation, like this patient, if they don't even have health insurance to be able to get to the clinic, or if they don't have adequate social support, they are likely not to do well. And social support, for instance, they may not even be candidates for advanced therapies if they don't have adequate social support. So excellent. I think you did very well on this question. And I can take any other questions that may be in the chat. I think most importantly, as well, we saw some improvement in the questions from the first time we took the questions into the second time after the lecture. So I think that everyone's made a great investment tonight, in tuning in with us for some excellent learning in preparation of the heart failure start exam. So we do have a question from Megan in the in the chat, it says, does the certification exam want us to know the level of recommendation for each guideline? And Megan, I wouldn't expect them to ask the question that would require you to quote the level of recommendation. I think that the type of questions that you'll be seeing are going to be more general questions as far as how to imply or how to use the evidence more so than quoting the level of evidence. So you can feel assured about that. Yeah, I think they would just want you to know what one and two A are, because those are the ones where the evidence is strongest. And so they want you to know what they are rather than whether they are one or two A or, or etc. Yeah. And it's interesting, because most of them are actually like a level one. Yes. Yeah, so most of them are actually level one. But what I would want to say in addition is that it's important to understand the care setting. For instance, some of the performance measures are inpatient, outpatient. I mean, it's very fair to ask you, for instance, you know, like, you know, LVF assessment in that question, usually used to be, you know, both outpatient inpatient, but it's no longer there also to know the measurement domain, some of them are focused on diagnosis, some of them are focused on monitoring, some of them are focused on treatment, I think those would be fair questions, even though I'm not on the question board. Jen could speak more on that. Yeah. Yes. So this is question is from Jack, and this is for Dr. Yibong. So it seems like one question referred to the JNC. I thought that get with the guidelines was what Heart Failure Society of America lean to in reference page, just wondering if that could be clarified. So yeah, what we are using now definitely is get with the guidelines. But you know, it shows you the evolution that has gone on in heart failure performance measures. So that you have to understand what's the difference, you know, between the performance measures between the quality measures, you know, understand pay for performance, as opposed to fee for service. Actually, recently last week, there's a new article from the AHA talking about value based care, as well as, you know, still, you know, quoting these performance measures. So initially, it all started out with four performance measures, but this has evolved, you know, significantly over the years to talk about. So those are very interesting articles. I don't know if we, Jen, somebody could find and share it in the chat. I'm just released on person centered, patient centered models for cardiovascular care. And the data on this is really still evolving, as well as value based care. Right now for heart failure, we use get with the guidelines, which is really refined, which involves all the other measures that were not included in that question, like beta blockers, etc. But the initial, you know, performance measures started with the joint commission with those four measures that we mentioned in the question. Okay, I'm happy to share those references for those new articles. Wonderful question, how long will we have access to the presentations online? And so your registration for the session tonight will include a one year access to the on demand recordings in the Learning Center. So you can refer back to them as you're preparing for your exam. I think the important thing is they'll be there till the exam. So don't have to worry. I know somebody said they joined in late. They'll be there till at least the exam date and longer. I think these are very useful concepts. Jen, I would say that when I was a fellow, we didn't get, I guess I didn't really understand the impact of performance measures, value based care, as well as pay for service. You know, until I started practicing. We have people that are just focused on quality that we view all these things that make sure and our hospital is part of the get with the guidelines. And for several aspects in my hospital, we have developed a protocol that kind of standardizes because we have data showing that standardized care always improves health failure. So we have standardized is because we have data showing that standardized care always improves health failure outcomes, not just for advanced health failure, because, you know, that's really common for patients with heart transplant or, or LVAD, but also for patients with, you know, just the traditional, you know, heart failure. And that really improves. And another thing I think very important in this distress is just the importance of education, ongoing education. So the data presented was just for nurses, but education involves everybody. You know, there's another question in the chat, you know, it involves everybody, not just nurses, but pharmacy, etc. Dr. Yvonne Carroll asks, I struggled with the concept of value based care and how one gets paid for this. Could you briefly explain the concept? What does it mean to you? Yeah, so from the article, which I'll be giving to Cynthia, value based, so initially, heart failure used to be a fee for service. So my understanding, you know, from, you know, all the data reviewed is that you used to get like a bulk of money, you know, for pay for, but these days, people actually, when you talk about value based care, value based care is actually reflected on the performance measures that you've outlined. So if you show that you, you know, documenting the left ventricle ejection fraction, you are sending patients for cardiac rehab, your how much percent, you know, how much is your hospital compliant with the use of beta blockers? How much is your hospital compliant with the use of ACE inhibitors and ARNAs? Measuring lab assessments when you start patients on spironolactone, plenarone, etc. So it's not just that meeting the patient and discharging, and then another system, another metric that is really assessed is heart failure readmissions, you know, in a one month setting. So it's different from just admitting, discharging the patients, but your program is actually going to be, you know, judged on these various metrics that we talked about. And some of them, four of those metrics are just quality measures, you know, the four that we mentioned, even though they have evidence, but you know, they are, they are not included in the pay for performance program. So pay for performance programs are the first 13 performance measures that we talked about. And then there are also the structural measures, you know, things that look at cardiac rehab with in patients and outpatient, and some of them actually evaluate the institution. So the measurement and the assessment goes across various domains, and, you know, various, you know, parts of the institution as well as the heart failure program. Well, we have just a few minutes remaining. I don't know if there are any final remarks, I guess that I would like to ask each of you, perhaps, what was the most interesting thing that you learned in preparing for your talks today that you really take with you? So I'll let Dr. Purnima go first. Okay. Well, you know, for me, you know, I've always known that prevent being a preventive cardiologist, more, which is always geared towards more atlas grosses, you know, most of our prevention has been there. But I think that it's very exciting that we have good data now very good evidence based care on prevention of heart failure, which is very powerful. And that's the message I wanted to get across. So I, you know, and then looking at some of the lifestyle data was very helpful for me also, or lack of it, I should say. And Dr. Yvonne, same question to you. What's your favorite? Um, I would say that for me, one of the things I really realized while I was doing this was just the importance of standardization of heart failure care. And then standardization is really based on, you know, the evidence that, you know, we've talked about, you know, it's not just you doing your thing. And the second thing I also learned was just the importance of team based management, collaboration, as well as communication. Heart failure is not a one person business, I would have to say, the more complex and the more advanced it gets, every member of the team has a crucial role to play. In my program, I would say for instance, because you know, for for each and every one of you, I'm sure it varies in your different systems, everybody has a role. And nursing practitioners in my program have developed a system where they actually have a care model for every single patient, every patient is different. And the specialty pharmacies helps in provision of medications, for instance, improving access to care, for instance, patients that don't, you know, have, you know, can't afford, for instance, we're talking about families for treatment of amyloid, which is very expensive, social worker helps in arranging transportation. Now, we talked about these social determinants of health, which are so important, getting patients to, so two things for me, one, it's really the importance of standardization in management of heart failure, and two, just the role of team based practice in managing heart failure patients. Thank you so much. Something that you said, Yvonne, that Emo, that was struck me is that you said that many of the nurses when they did that they, you know, their performance on the question on their education wasn't very good. So I think we probably need to standardize education also, you know, if we say the discharge instructions are important, clearly they are, they make a difference on outcomes, you know, hospitalization, then we have to make sure that they are accurate, and done properly. So maybe one of the things we need to standardize about, you know, discharge planning, and the transitions of care is, is some standardization of, of, of education. And this is one forum, you know, where people who should be maybe taking these courses are not just people who deal with heart failure patients, providers, you know, in terms of prescription, but even in terms of systems of care. That's an excellent point. For interest of time, we have to end now. I'll ask the Heart Failure Society of America team to put up the closing slides for us. And we do have one final question, Diane, about guideline directed medical therapy. And I encourage you to join us with our next session, because we're going to be speaking a lot about GDMT, and how to implement GDMT. So please stay tuned for that. And so for our closing slides. Our day two assessment part in two will be July 18, from 6 to 8.30pm Eastern Standard Time. And so I hope that you all will join us for that coming up very soon. And finally homework that you have for next time. This is actually this is the presentations for the next time. A couple follow up details, a brief survey will be sent by email following each webinar. We really appreciate your feedback and we will implement implement your feedback into our next session. So please share. The zoom link for the next webinar on July 18 will be sent the day before. And please feel free to visit the heartfailuresocietyofamerica.org Heart Failure Society of America Heart Failure Virtual Boot Camp to view the next webinar agenda and faculty and on demand listing will be posted there as well. And finally, your homework between now and July 18. On the Heart Failure Society of America website is a heart failure certification, detailed website. On this website, you will see a list of topics on all that that were used to develop the lectures for each of these sessions that you'll be participating in over the next over the three boot camp sessions. And so your homework between now and July 18 is to go to the heart failure certification website, make yourself familiar with what the different topics are that will be on the exam to help prepare you for our next learning session. And so with that, we drew up we draw this evening to a close. I want to thank so much our speakers for joining us this evening and for really running a very vibrant question answer session and providing some terrific didactic lectures. Look forward to seeing everyone back on the 18th. Thank you, and good luck.

heart failure

LVEF assessment

treatment decisions

discharge instructions

ACE inhibitors

beta blockers

social determinants of health

care coordination

value-based care

standardizing management

transitional care

readmissions prevention

team-based approach