Good evening, everyone. My name is Jennifer Cook and I am the chairman of the Education Committee for the Heart Failure Society of America. And part of our charge as a committee is to put together educational offerings throughout the year. And this is our Heart Failure Certification Bootcamp. And we're really glad that you've joined us this evening. We actually have a series of three different bootcamp evenings, and this is our second of three. And so some of you who are joining us this evening might be back for the second time. If so, welcome back. If this is your first bootcamp, you can catch the previous bootcamp. And I'll have the information on how to do that in just a moment. But what we have in store for you, next slide, please. This is assessment part one and part two. Our program chairs, myself, and we have Terri Dedrick with us today. She's one of our speakers tonight and program faculty. And we have Rebecca Ray with us, who's gonna be speaking this evening as well from the program faculty. So we're gonna get started just with the introduction here, and then we will have some audience response questions. So we'll have an opportunity to test your knowledge on the first section of material. And then following that, we'll have a didactic lecture followed by a question and answer session. Then we'll repeat it all over again. We'll have a second audience response question and answer session followed by didactic, and then our final question and answers. And so all the program that we're doing this evening is gonna be available on demand. And so registration for your virtual bootcamp tonight gives you one year access to on demand. And it's accessible in the Heart Failure Society of American Learning Center under my courses. And it will be available two to five business days following the last webinar, which is scheduled for July 25th. And so now without any further ado, I introduce Terri Diederich, who's gonna be with us tonight talking, giving us our first didactic lecture and starting off with your challenge questions for our participants. Yeah, as Dr. Cook said, my name is Terri Diederich. I'm a nurse practitioner that's been caring for heart failure patients at Nebraska Medicine for over 15 years now. So I will just wait for them to pull up the slides for the initial questions and I'll pull the audience and let you think about those. And then afterwards, we'll review them again. So the first question that we have here is, which is not recommended in the initial assessment when you suspect a patient may have heart failure. This is a patient that doesn't have a diagnosis of heart failure and you're thinking they may have heart failure. So A, clinical history, B, physical examination, C, laboratory testing and EKG, and D, heart catheterization. That's a good start, you can go to the next question. Okay, question number two is, which patient's complaints are consistent with heart failure? A, increased energy, increased appetite, increased fluid intake and ankle swelling, B, decreased energy, snoring, weight gain, weight stable, excuse me, no cough or shortness of breath, C, decreased energy, shortness of breath, bendochnia and early saiety, or D, increased energy, abdominal pain, nausea and vomiting. Okay, I think it looks like almost everybody's answered if we want to move on to the third one. Question number three, which physical examination is most consistent with heart failure? A, jugular vein distention, RV lift, abdominal distention, lower extremity edema, B, no jugular vein distention, soft abdomen, trace pedal edema, C, no jugular vein distention, positive hepatojugular reflex and elevated blood pressure, D, altered mental status, normal blood pressure, no jugular vein distention and positive bowel sounds. Okay, looks like most of you are reading faster, reading these faster than I'm reading them to you, so I think we can go on to the next question. And then question number four, the Seattle heart failure model is used to, A, assess for acute decompensation risk, B, estimate one, two and three year survival in heart failure patients using clinical data, C, determine readiness for discharge using clinical data or D, determine the risk of a patient developing heart failure. We've had excellent participation this evening in our questions, so we appreciate that from everyone. And I think that's the last question. And then we'll now move on to the lecture portion, correct? That's right. Thank you. Hello, on behalf of the Heart Failure Society of America, I would like to welcome you to the HF CERT virtual bootcamp. My name is Terri Diederich and I will be presenting part one of assessment for our bootcamp today. Here are our program chairs for this activity, as you can see, and here are our program faculty that are speaking on our various talks at our virtual bootcamp. These are my disclosures, as I said, my name is Terri Diederich, I am a heart failure specialist and my name is Terri Diederich, I am a heart failure nurse practitioner at the University of Nebraska Medical Center in Omaha, Nebraska. I do not have any financial disclosures related to this talk, but I would like to say that I did take the HF CERT examination and pass this as a practicing member of heart failure care for our heart failure patients. I felt that this exam was important for me to take to show my knowledge in caring for heart failure patients. As we discuss assessment of the heart failure patient, we're going to start with a case study. Our case study starts with Joe Jones. Joe Jones presents the emergency room with dyspnea and headache. He also complains of pleuritic chest pain and nausea and he cannot do the activities that he was able to do two weeks ago. In further discussing with him, you find that he is a 43 year old male with no known past medical history. Also in talking to him, he was seen in your emergency room nine days ago for dyspnea. During this evaluation, he was found to have pulmonary edema on his chest x-ray versus an atypical infection. He was discharged home with doxycycline and instructed on when to return to the emergency room if symptoms did not improve. Joe states for about the past nine days, he's been continuing to be more short of breath. He has taken his antibiotics and has not missed a single dose. He states that this has helped his shortness of breath with somewhat, but he still remains short of breath with most activity and cannot exercise as much as he used to. A month ago, he was very active and did not have any limitations. And now sometimes just walking up and down the stairs, he feels short of breath and has to rest. He also states in the past one to two days, he's had a severe headache. He's taken Tylenol and this has not relieved this. He states that he's not had a headache like this before. When asked further about the pleuritic chest pain, he states that this can come and go with exertion and feels like there's something tight in his chest. In review of his social history, he only drinks one beer a week. He does have a previous history of smoking cigarettes for 10 to 15 years. He used cocaine in his 20s, but has not since then. He also uses injectable anabolic steroids and has injections every five days. When we think about this patient and all patients that come into our emergency room, we need to follow the guidelines when we suspect that they're potentially have heart failure. As you can see here, the newest diagnostic algorithm for patients with suspected heart failure was published in the spring of 2022. And like evaluation of patients for other medical conditions, evaluation of a patient when you suspect they have heart failure begins with a good assessment. You need a good clinical history, a good physical examination, and then a good electrocardiogram and laboratory data. Taking that a step further, you are looking at laboratory data such as your NT pro BNP, which is greater than 125, or your BNP, which is greater than or equal to 35. In addition to other laboratory data that may suggest signs of poor end organ function, suspicious or leading to heart failure. Once you have this, your next step is to order a trans thoracic echocardiogram to confirm your evaluation of heart failure and cardiac dysfunction in this patient. And then there's potentially other testing that we will talk about further down the road. Once your heart failure diagnosis is confirmed, you look to determine the cause and classify. As you can see here, we want to determine if the patient has heart failure with reduced ejection fraction with the EF less than 40%, heart failure with mildly reduced ejection fraction with the ejection fraction of 41 to 49%, or heart failure with preserved ejection fraction when their EF is greater than or equal to 50%. Once you've determined this, you look for precipitating factors and initiate treatment, which will be talked about in our third webinar. When we think about all of the history when talking to a patient, this can be very extensive, especially if this is a brand new patient to you. Looking at signs and symptoms that are related to heart failure can help lead you in your diagnosis. When you talk about your history of prevalence and illness and your review of systems, some of those general symptoms can include weakness, fatigue, confusion, swelling, and decreased activity tolerance. It's very important when talking to a patient about activity tolerance to ask what they can do comparatively to what they were doing a few weeks ago. Some patients' baselines may only be that they can walk a block to begin with and going down to half a block is very significant for them, whereas other people before were able to walk two miles and now they're only walking a one mile and that's still a significant change. Patients with decreased cardiac output can have confusion and altered mental status, so it's important to also look at this. Some patients will just complain of generalized fatigue, that they just can't do what they used to. They wake up and they're not tired. They're not as energized as they were before and are more tired. When you think about respiratory complaints, patients who have shortness of breath, either at rest or when getting up, patients who have the dyspnea on exertion that before were able to walk up two flights of stairs and now can only get half a flight of stairs before they have to rest. Patients who have cough or wheezing are also important to note. When we think about cardiac complaints, patients can sometimes have chest pressure. They can also have chest pain, which is related to ischemia. We need to ask patients about bendopnea, the symptom of when you bend over, you become short of breath. Some patients also have PND where they wake up short of breath at night sleeping and orthopnea where they wake up gasping. When you think about the GI system, you also need to think about abdominal bloating, abdominal swelling, decreased appetite, early soiety, just end stage heart failure. You can have some nausea and vomiting. And then when you look at peripheral symptoms, you need to look at swelling. Do they have ankle swelling? Peripheral swelling. Do they have jugular vein distension? When we think a patient has heart failure, then you want to look at their past medical history to see of any comorbid conditions that can be leading to this. Some of those include hypertension, diabetes, obstructive sleep apnea, coronary artery disease, any cardiac arrhythmia or any recent viral illness that may have led them to become sick. When we look at medications, in addition to the medications that they're currently taking and doing a complete review, you want to look at medications that are known to be potentially cardiotoxic. These include stimulants like some of our ADHD medicines, some chemotherapy agents and even some rheumatoid arthritis treatments. And then when we talk about social and family history, we want to look at all their previous, to know their alcohol consumption, their tobacco consumption. Are there any illegal or street drugs that they've been using? Any supplements that they may have been taking? And this includes anabolic steroids, testosterone, either injections or oral supplementation and even some of the multivitamins. And then you also want to make sure that you're talking to patients about their family history of heart failure. When we look at physical examination for heart failure to help lead us to this diagnosis, there are many things that we should be looking at as we do a complete head-to-toe physical examination. First thing you want to look at is vital signs to look at blood pressure, heart rate, oxygen saturation. See if they have signs of adequate perfusion. Then generally you want to look at mentation. You want to look for scleral jaundice. When you evaluate their neck, you're looking for jugular vein distension. When you talk cardiovascular, you're looking for signs of an S3, a murmur, an RV lift. When you look pulmonary, any signs for decreased breath sounds, any wheezes or rails. When you talk gastrointestinal, is there any abdominal bloating, abdominal tenderness? Is there hepatojugular reflex? Can you palpate their liver? And when you look at peripheral vascular, you want to look at lower extremity edema. Is it pitting or non-pitting? Once you've done your physical assessment, it's helpful to look at patients based on Forster classification. This helps to look at perfusion and filling pressures. When we talk about perfusion, we're talking about our cardiac index. So is this patient adequately perfused? Are they getting enough flow to all of their cardiac organs that they're doing okay there? Do they have adequate blood pressure for their current state? Or are they hypotensive? And then you also look at their filling pressures. Do they have signs of jugular vein distension, abdominal bloating, lower extremity edema, which would show elevated filling pressures. When we think about heart failure patients, the goal is to have these patients warm and dry so that they're adequately perfused and not fluid overloaded. And then as they'll talk in the third webinar, looking at these can help guide your treatments for when they are warm and wet, cold and wet, and cold and dry. As you can see here, these are the recommendations from the American Heart Association, Heart Failure Society of America and the American College of Cardiology. As we're reviewing the guidelines for clinical assessment for history and physicals for patients with heart failure, you can see the recommendations below. These recommendations were created by the American Heart Association, American College of Cardiology and the Heart Failure Society of America. As we've said before, if patients have heart failure, vital signs and evidence of clinical congestion should be evaluated at each encounter to guide their management, including their diuretics and other medications. In patients who present with symptomatic heart failure, any clinical factors that may have made their heart failure worse should be evaluated in the history and physical examination. If a patient is found to have heart failure, a three-generation family history should be obtained or updated to determine if the cardiomyopathy is possibly inherited. In a patient who's presenting with symptoms of heart failure, your history and physical should direct further diagnostic strategies to look at potential other causes, excuse me, to look at potential causes of their heart failure and other treatment options available to them and guide your therapies. And as you can see on the last recommendation, in patients that present with heart failure, you should evaluate for cardiac and non-cardiac disorders and also lifestyle and behavioral factors that could accelerate or aid in developing heart failure. When we talk about evaluating for risk of heart failure decompensation, it's very important to understand the pathophysiology of heart failure so that we can understand what leads to their decompensation. In the most, whether we talk about heart failure with preserved or reduced ejection fraction, both cases, the patients have some sort of myocardial injury that leads to reduced cardiac output. When this happens, the sympathetic and renal angiotensin-aldosterone system are upregulated, which increases heart rate, increases vasoconstriction, increases blood pressure, leading to symptoms of heart failure. Some of the most common causes of heart failure decompensation are listed here. As we think about these, we should think about how they affect myocardial perfusion. When we talk about cerebral and peripheral vascular disease, while this is not within the heart, this is our perfusion within our body and our circulatory system. So if something happens and the patient has a stroke or they have peripheral vascular disease, this changes the blood flow and can lead to myocardial injury or decreased oxygenation, causing the heart to have to work harder for this, for oxygenation and cardiac output. Acute coronary syndrome and valvular heart disease are very common causes of heart failure. These directly affect the myocardial tissue in the heart, causing injury, causing decreased oxygenation and can lead to heart failure for these patients. Longstanding hypertension can lead to left ventricular hypertrophy, the heart dilating out and becoming less effective and having decreased oxygenation in the heart leading to heart failure decompensation. Coronary artery disease, as we've talked, is very similar to acute coronary syndrome and can lead to heart failure decompensation by altering the blood flow within the heart and your cardiac output. Atrial fibrillation is also a common cause of heart failure decompensation. When a patient is not in normal rhythm, they don't have normal filling of their atrium ventricle and this leads to decreased cardiac output and decreased myocardial oxygenation and heart failure. When a patient has heart failure, we also need to look at nutritional deficiencies in heart failure. Many of these patients have sodium and fluid imbalances that we need to help manage. We need to manage their ins and outs and their sodium that they consume in their diet to help prevent decompensations and fluid retention. We also need to look for thiamine deficiencies for these patients, for iron deficiencies in these patients and vitamin deficiencies in these patients. We're now gonna go back to our case. When Joe was seen in the emergency room, he had a very broad differential diagnosis. These included heartburn, GERD, pancreatitis, cholecystitis, nephrolithiasis, a small bowel obstruction, a urinary tract infection, a viral respiratory infection, acute coronary syndrome, pneumonia, pneumothorax, a pulmonary embolism, heart failure, or COPD. He presented with a broad range of complaints, including the pleuritic chest pain, the headaches, the shortness of breath, some abdominal pain and had an extensive evaluation. His physical examination showed a vitals of 36, a temperature of 36.4, blood pressure of 131 over 93 with a MAP of 105, heart rate of 87, respiratory rate of 20 and oxygen saturation of 96%. On presentation, he was mildly short of breath but not in acute distress. He did not have jugular vein disjunction. His lung sounds were clear. He had a normal rate and rhythm. He was slightly tachycardic but in sinus rhythm. He didn't have any murmur, rub or gallop. His abdomen was soft without any palpable masses and he did not have hepatojugular reflex and he only had trace petal edema. Once his physical examination was done, laboratory testing was recommended. These are the current guidelines for testing when heart failure is suspected in a patient. For patients presenting with heart failure symptoms, the heart failure cause should be explored. For patients who are diagnosed with heart failure, laboratory evaluation should be included. This should include a complete blood cell count, a urine analysis, serum electrolytes, including your blood urea, nitrogen, your serum creatinine, your glucose, a lipid profile, liver function tests, iron studies and thyroid studies. All patients presenting with heart failure should also have a 12-week EKG performed to rule out acute coronary syndrome to look for cardiac arrhythmias and assess for any signs of left ventricular hypertrophy. Joe did have laboratory data that was drawn. His sodium was slightly low at 132. His potassium was normal at 4.5. He does show a mildly elevated creatinine and has not had laboratory data recently to show his baseline. His calcium was normal. His blood sugar was normal. His D-dimer was slightly elevated. He had a TSH, which was drawn, which was normal, a hemoglobin A1c that was normal. His white blood cell count was mildly elevated. Hemoglobin was stable and platelets were normal. His troponin was 23 with a delta negative. His CHF peptide was 170 with the cutoff for normal being 100, so it was elevated. He had a urine drug screen, which was negative, and a hepatitis panel, which was negative. As we continue to look at the recommendations for evaluating patients with heart failure, guidelines will tell us that heart failure risk assessment should be used for scoring our patients. The American Heart Association, American College of Cardiology and Heart Failure, the Society of America all recognize that validated multivariable risk scores may be used to estimate subsequent risk in patients. There are different scoring tools that are used for different patient populations. They are listed here. For patients with any type of chronic heart failure, you can use the Seattle Heart Failure Model, the Heart Failure Survival Score, the MAGIC, the CHARM Risk Score, the Corona Risk Score. And for chronic heart failure, chronic heart failure with reduced ejection fraction, the risk scores include Paradigm HF, HF Action, and Guided. For chronic heart failure with preservative action, ejection fraction, the risk scores include I-Preserve Score and TopCat. And for patients with acutely decompensated heart failure, you use the ADHEAR Classification and Regression Tree, the AHA Get With The Guidelines Score, the Affect Risk Score, and the ESCAPE Risk Model and Discharge Score. The Seattle Heart Failure Model is used for patients with chronic heart failure. It is a tool that is estimated survival using clinical data for a patient. These are used in the ambulatory setting. You can plug in their information as listed on this chart here, and you can get one, two, and five-year survival for these patients. A link to this tool is below. This has been validated in multiple studies and is useful in an ambulatory setting for patients with chronic heart failure for survival. The other score that has been validated and is widely used is the ADHEAR Score. This is the Acute Decompensated Heart Failure National Registry. This is to be used for patients with acute decompensated heart failure. It is used for risk stratification, triage, and optimization of medical management. I have the scoring here and it is blank. The first two questions is, is your BUN greater than 43 and is your systolic blood pressure less than 115? If you answer no to both of those questions, you have a 2.1 to a 2.3 mortality risk from acute decompensated heart failure. If you answer no to either of these questions and yes to the other, so answering no to one and yes to the others, regardless of what you answer yes and no to, your mortality risk is between 5.5 and 13.2% for acute decompensated heart failure. And if you answer yes to both of these questions and the patient has a creatinine of greater than 2.75, your mortality risk for acutely decompensated heart failure is 19.2 to 21.9%. These are the references here. I'd like to thank you for listening to the initial portion of the assessment for the HF CERT virtual bootcamp. And we will continue our assessment in Joe's case in part two. Thank you. Well, thank you so much, Terry. That was great. Thank you. So I think that really lays the groundwork, you know, and I love that you brought this patient to us because it really makes it relatable to everyone because this is absolutely what we're doing every day is taking care of patients like Joe. And so it really brings it alive. So we're going to move on to the question answer session. We have 10 minutes here that we're going to spend just honing in on some of the topics that you brought up and we'll start with the Q&A. So we'll go ahead and bring back the questions and pull the audience again after the lecture to see how we're doing. Terry, you mentioned before that they could read faster than you could read to them, so. Yes, I was going to start and then I looked and I'm like, oh, they've all responded. Yeah, yeah. So this question is the initial assessment. When do you suspect a patient might have heart failure and what is included in the official assessment? So we have had people who've joined us since we started these questions. So we have more participants now than we did at the beginning. But this was one that the first time we surveyed the audience, the majority said heart catheterization. Terry, what do you think of that? I would agree the heart catheterization would not be part of the initial assessment. I think once you have your initial, you know, you talk to your patient, you have a physical examination and you look at some laboratory values and EKGs that may lead you to heart catheterization, but I don't think that's where you're jumping to. And I think our audience all agreed with that. Now, as we're on this question though, I'd like to ask you a little bit about your practice and what you guys do in clinic. Do you guys have order sets that you use in your EMR for the laboratory testing? And are there any tools that help you with that? So we have a heart failure admission order set that if we have a suspected heart failure that all the laboratory testing is there, including, you know, your CBC, your CMB, your heart failure peptide. We also added iron studies to this in the last six months. We also, in the inpatient setting, developed a focused heart failure order set. So if you've had a patient that's been admitted for a while, say they had some sort of surgery and now the team's thinking maybe they're developing heart failure, you can go in without that whole order set and you can get the recommendations in that just for, I think they have heart failure, help guide me on these are the labs, these are some of the other testing. So we definitely have that built. That's helpful, for sure. Yes. I just want to remind everybody who's in the audience that we do have the chat open. And so I have that open here as well in case there are any additional questions or any follow-up questions for our speakers. All right, let's go to question number two. I can read it again. They're probably going to beat me. Which patient complaints are consistent with heart failure? A is increased energy, increased appetite, increased fluid intake, and ankle swelling. B is decreased energy, snoring, weight stable, no cough or shortness of breath. C is decreased energy, shortness of breath, bendopnea, and early sanity. And D is increased energy, abdominal pain, nausea, and vomiting. Okay. Great, we can go ahead and share the responses here. Yeah, I mean, I think 100% agreed with me that C is the correct answer. You know, I did some different variations in all of these, but I think, you know, when you truly think about these patients, they don't have the activity tolerance that they used to. They're short of breath. The bendopnea one is, I think that when I first started doing heart failure years ago, I didn't really understand. Like people would say, well, when I bend over, I can't really breathe. And I just didn't correlate. But now that is one that you really see. And then the other ones are the patients that truly like, well, I can't eat what I used to. You know, I'm not eating as much, but I'm gaining weight or my weight's stable. And that's truly just, they can't eat what they used to. Yeah. And I have also noticed over my career that there's a certain type of patient. You know, there are patients that swell in their legs and that's really reliable. And other patients that have more elusive edema that swell in their belly. And then the questions like the bendopnea and the early satiety really kind of helps in that situation to classify whether they have congestion or not. Rebecca, is that something that you see in your practice too? Patients that have more abdominal symptoms? Absolutely. And even that it'll change over time. Patients will initially present with lower extremity edema and later in their course, they stop having lower extremity edema and now they always have abdominal edema. So yeah, it definitely varies from patient to patient and even within the course of the patient's lifespan. Terri, there's a question for you about the CHFP. And the question is that, is that the same as the BNP or interchangeable with BNP? So they are similar, but they're not exactly the same. So some labs will draw your NT-proBNP and some labs will draw a CHF peptide. NT-proBNP is more accurate, especially if you have a patient on Entresto and Entresto can adjust your CHF peptide. We'll tell you in our organization, we've pushed the lab to change to NT-proBNP and they haven't jumped on like we have, but wherever your area is, they have reference ranges on what is normal. So you will look and you trend it. I think the biggest for us is when we get labs from an out-facility that looks at NT-proBNP, it doesn't exactly correlate with our labs. So we need to look at their reference range at their lab as to how elevated it is comparatively to how elevated they've been at ours. Okay, so you're basically using it the way that many of us use BNPs. Yeah, it's used very similarly. It's just more of our lab has not wanted to change the labs and the assays and get the new machines and everything that goes along with that and capital dollars. And how expensive that is to change. So there's another question for you in the chat. So Terry, and this is from Diane. She asks, you mentioned vitamin deficiencies. Outside of iron studies, do you routinely check any others? I would say sometimes we check vitamin B and sometimes we check vitamin D levels, but it's not extremely routine. I don't know if you guys in either of your practices have it as part of your regular order set or more just if you're looking for a patient with heart failure with continued symptoms and everything else is looking stable. Yeah, I think that if someone has a history of like alcoholic cardiomyopathy, I might be more inclined to check their thiamine levels and their B12 levels and everything. But otherwise, and there's been a rare occasion when I've suspected anorexia that I've been more thorough in nutritional testing and got a nutritional consult. I would say we commonly check vitamin D levels. All right, let's move on so we don't run out of time. Let's see, question number three. Okay, so number three, which physical examination is most consistent with heart failure? So, A, gyro-vein distention, RV lift, abdominal distention, lower extremity edema. B, no gyro-vein distention, soft abdomen, trace-pedal edema. C, no gyro-vein distention, positive with bad adrenal reflex and elevated blood pressure. Or D, altered mental status, normal blood pressure, no JVD and positive bowel sounds. And that looks like a little over half the people are giving them a few more seconds on the polling. We have about 70% in. Okay, we have almost everyone there. And so far everyone is agreeing with A, and I would agree with that, that patient's gyro-vein distention, RV lift, abdominal distention and lower extremity edema. I will say that not necessarily every heart failure patient has all of those and gives you the slam dunk evaluation of yes, I can see your neck veins from the door and your stomach's bloated and your legs are swollen, but that description is the most consistent with what you're looking for for heart failure patients, at least in my experience. And one of the things that I reflect back to at the bedside because I never round by myself, I'm always rounding with the residents and the medical students and everything and how being able to elicit the JVD on physical exam, especially being able to determine in the presence of hepatojugular reflux is so helpful as part of the clinical exam in a heart failure patient for assessing their volume status. One of our MPs though in clinic threw me a fastball recently where he brought the point of care ultrasound and asked me to help him find the IBC in the clinic. And I think we are getting more technologically advanced as some of us have a point of care ultrasound available as well. But I think that those tried and true ways of looking at volume status is so helpful. And it's really illustrated by this question. So this is from Haseem, the question, do you routinely use point of care ultrasound for volume status? I've used it once now. My MP brought me the ultrasound and asked me to find the IBC, which I was able to do. I don't do echo as a heart failure specialist, so I was glad, but how about the two of you? Do you guys have ultrasounds in your clinic? Are they available to you? We don't have it in the clinic. I will say the fellows, we have like three handheld echo machines that if we're concerned, we can call them and they can go look inpatient. And I will say our emergency room staff is very well trained on bedside echo and can, you know, if they suspect heart failure can easily get what the IBC likes and gross function to then lead them to order a full echo, but not in clinic. Yeah, same here. And so the next question, and we'll keep taking these questions as long as we have time, because I think that that's the most useful. Do you have a population you tend to do non-invasive testing like nuclear stress? Are cardiologists like looking for CAD? So I would say yes, and I would say it also depends, it doesn't always have to be nuclear stress, but I think in the guidelines, when you're assessing and you see that the patient has heart failure, your next step is to determine what caused it and what's potentially reversible that you can fix. And I think Becky talks about this in the next session, but one of the very first things you should be looking at is, is this an ischemic cardiomyopathy? Is this coronary disease that you can fix and give them better blood flow so that they have their best chance of improvement in their ejection fraction? So whether your center is huge in nuclear stress testing or your center is huge in dibutamine stress echocardiograms like ours, or adenosine MRIs, which we're getting more used to as long as insurance will cover stress testing to look at coronary disease, I think is next steps on patient care. So we'll circle back to that again at the next question and answer session. But before we run out of time, our fourth question we went ahead and pulled. Can you tell us a little bit about the Seattle Heart Failure Model? The majority of people think that it's an estimate of one, two, and three year survival. Yes, and based on that, they're right. So the Seattle Heart Failure Model is used for long-term risk stratification. It's not something you want when the patient is acutely decompensated in the hospital. This is more for your patient. Okay, I've been seeing you for a period of time. I have more than one set of laboratory values. So I can trend this, I can put the risk score in, and I can tell you survival-wise. And what we always talk to patients about is the main thing in this is every time you're admitted, your mortality goes up, and that is looked at in the Seattle risk. So we always talk to patients about, you know, when they're in the hospital, like this is worsening your mortality, you're admitted more, we need to be figuring out how to keep you out of the hospital and what our next steps are. I want to make sure we get an opportunity to ask Terry this. This question is for you, being our certified heart failure cert speaker tonight. These questions seem very good, but they're simple. Are they supposed to be similar to the exam questions? So I would say as a person who took it, these are yes, somewhat similar. Yes, some of them are harder, but I don't think that the exam was built to trick people who are practicing caring for heart failure patients. Some of them, yes, seem very straightforward, but it's also testing your knowledge to say, I've been caring for a heart failure patient and I know what I'm doing and this is validating my knowledge and this is why I'm taking the certification. I will say all of them are multiple choice. They're all along this line of, especially in the assessment portion of how you assess your patient, what are your next steps and what are some of these risk scorings? I'm going to take the chair's privilege and ask you one more question because I think it's really great that you're here with us tonight. What suggestions would you have, this is coming from Diane, on prepping to take the test? So the main thing that I looked at in this is the resources that when you have the HF cert on the website, there's a link to the different resources and documents that they looked at. And I looked at those. So I brushed up on, in addition to the most recent guidelines, I brushed up on like management of heart failure patients with other medical comorbidities. And that will be more in the third webinar, but you know, your patient has heart failure and AFib, what are the right things? Your patient has heart failure and peripheral vascular disease or end-stage renal disease. How do you kind of manage some of those? And then also brushing up more in the next session about guideline-directed medical therapy and which are the right meds and which meds may counteract with each other. So giving this, but not this. All right, Terri, there's one more question for you in the chat. I'm going to ask you to respond to that during Rebecca's talk a little bit later. Okay. So we can keep moving and we are going to move on to our second set of audience response questions for the second part of our lecture this evening. So I'm Rebecca Ray. I'm a nurse practitioner at the Cleveland Clinic in Cleveland, Ohio. I'm very happy to be here tonight with you guys. And we're going to move on to our second set of pre-knowledge questions related to assessment. Question one, true or false, a Holter monitor may be ordered for an asymptomatic patient when assessing for cardiac arrhythmias. Okay, we can move on. Question two, routine reassessment of LV function is not recommended except when the patient is clinically stable. No treatment intervention has been done that is likely to have a significant impact on cardiac function. The patient is a candidate for invasive procedure device therapy or the patient is being referred for palliative care. Interesting. All right, let's move on. Question three, the following are part of a routine evaluation for new onset heart failure except A, an ECG, B, endomyocardial biopsy, C, transthoracic echo, or D, chest x-ray. Great. Okay, we can move on to question four. Question four, which of the following measurements should prompt evaluation for cardiac transplantation? A, peak VO2 less than 12, B, capillary wedge pressure of greater than 16, C, right atrial pressure greater than nine, or D, cardiac index less than 2.4. Okay, great. We'll be coming back to these after the lecture. There are a couple that were interesting. We'll have to see if we have changes after the lecture. What is this? So we'll be standing by as we bring up your slides. Great. Hello. Welcome back to part two of assessment for the Heart Failure Society certification exam. My name is Rebecca Ray. I'm a nurse practitioner at the Cleveland Clinic in Cleveland, Ohio. I work in the ambulatory heart failure department. I have no disclosures for this presentation. These are the program chairs and faculty. So getting back to our patient, Mr. Jones now needs to undergo a series of baseline cardiac testing. When we're thinking about cardiac imaging, starting with non-invasive imaging, we have several class one recommendations, starting with a chest x-ray, a transthoracic echo, and then you want to think about repeating your transthoracic echo after the patient's been optimized on guideline-directed medication. And you're thinking about invasive procedures or devices. Or if the patient's had a significant clinical change, you want to get another evaluation of their ejection fraction. Cardiac MRI or cardiac CT are indicated if the echo is inadequate for any reason. Some class two recommendations for cardiac imaging, MRI may be useful for some patients. We'll get into that a little bit later. And ischemic evaluation is typically indicated to identify or rule out the cause of the underlying cardiomyopathy. Of note, you don't want to routinely repeat LV assessment if the patient's stable and there's no planned interventions or invasive procedures or device therapies that are being considered. So Mr. Jones' chest x-ray. Clinical common findings for congestive heart failure on chest x-ray would be pulmonary edema, pleural effusions, and pulmonary congestion. He shows all of this. He has curly B lines, encephalization of the vessels, increased cardiothoracic ratio, and pleural effusion. On EKG, you can see dilated cardiomyopathy with diffuse ST segment changes, and he has an intraventricular conduction delay with a QRS of 158. His transthoracic echo shows a very dilated left ventricle and a severely reduced ejection fraction of 15%. So overall, his left ventricle is severely decreased, so is his right ventricle moderate to severely decreased, and he has mitoric regurgitation that is secondary to his dilated cardiomyopathy. So his diagnosis from this would be dilated cardiomyopathy with severe biventricular dysfunction and moderate functional mitral regurgitation. And again, the functional mitral regurgitation is secondary to the dilation of the left ventricle. So what is the underlying cause of his heart failure? It's important to note that when evaluating patients who are newly diagnosed with heart failure, it's often a nonlinear process. You're looking at many different things all at the same time and in sequential visits with the patient or touch points. So physical exam, your laboratory tests, your diagnostic studies, all overlapping with the patient's history as it presents and digging deeper until you can find the underlying cause of the cardiomyopathy. The next thing we need to consider is a holder monitor, and this will allow us to assess for cardiac arrhythmias, for conduction abnormalities, and this can be in symptomatic or asymptomatic patients. These can be used for as little as 24 hours or up to years if you do something like an internal loop recorder. The benefit of this over a traditional cardiac EKG is that you can see the patient's cardiac rhythms during times of routine activity, but also, and very importantly, during physical or psychological stress, where sometimes occult rhythms can be detected. The patient does have a diary, often with the holter monitors, where they can document symptoms as they happen that can then be correlated to the EKG findings. So on a holter monitor report, you're going to get the total heartbeats, average heartbeat, max and minimum, number of premature beats, any tachyarrhythmias, ST segment changes, and you will get some EKG tracings. And again, the patient's recorded symptoms. So Mr. Jones's holter results, he had a minimum heart rate of 23 and max of 164, an average of 76, with an underlying rhythm of sinus. He had one run of VT, he had 38 SVT runs, and very minimal ventricular ectopy. So overall, we would conclude from this holter result that arrhythmia is not likely to be the cause of Mr. Jones's heart failure. So the next recommendation is to look for ischemia as a possible cause of his cardiomyopathy, and we want to look at the pretest probability of CAD. This is a calculator with a score that's based on age, sex, presence of chest pain, diabetes, hypertension, hyperlipidemia, tobacco use, and any EKG changes. Once you've done that, you want to look at the risk of Once you have this score, it's classified as low, intermediate, or high. If the patient's pretest probability is high, non-invasive testing typically is not used. Intermediate, you can do exercise EKG testing typically as first line, and then add other imaging when clinically appropriate. And we're going to get into that a little bit. If the pretest probability is low, often stress testing is not recommended because there is a higher false positive result. Exercise EKG testing, nuclear PET stress, and stress echo are all very well validated to diagnose CAD. So this is the table showing the sensitivity and specificity of various testings when diagnosing CAD, with exercise EKG being the least sensitive, all the way up to coronary CTA as being the most, being the most, and then in between. It's important to note that you want to exercise your patient for testing if at all possible. This is preferred over pharmacologic stress testing. Here is a comparison of the advantages and disadvantages of exercise testing versus imaging. So exercise testing is lower cost, more widely available, you can always do the imaging, and no radiation is given to the patient during exercise testing. Some advantages of doing imaging over exercise testing is you do have the option of doing pharmacologic when needed. It will help you localize ischemia if there is any present, and you get more info on the cardiac structure and function. So when is a cardiac CT indicated? It's typically done when you're looking to quantify and qualify coronary artery disease, looking for plaque and stenosis. It's non-invasive and very sensitive, with low false negatives, which is a plus, and it can rule out significant disease. It's also considered a strong predictor for future major adverse cardiovascular events. So some other ischemic evaluations are the nuclear PET stress with viability. This is non-invasive. It's going to look at the coronary blood flow, and it can evaluate for the presence of ischemia or scar. It can let you know if the patient had a silent MI in the past. It might be the cause of their underlying cardiomyopathy. And then left heart cath, the downside that this is invasive, but the opportunity is there to revascularize the patient as indicated, which is a real benefit, and definitely to be considered on our higher-risk patients. So Mr. Jones' pre-test probability for CAD was moderate, and he underwent nuclear PET stress testing with viability, and everything came back normal. He didn't have any signs of ischemia or scar, continuing to show his very severely depressed left ventricle. So at this time, we're going to conclude that his dilated cardiomyopathy is not a risk factor. He is not ischemic in nature. So when do we do a cardiac MRI? This is done to look at the functional and tissue properties of the heart, look at the chambers, systolic function globally and regionally, look at the tissue composition, valve and pericardium, also look for masses in aortic disease. It's typically done with more advanced and complex diseases, and after first-line testing has been completed, and we're still looking for a pulse. So Mr. Jones underwent cardiac MRI, and these were his results. It was negative for inducible ischemia. EF was still showing at 18%. RV looked a little better on his MRI, but he found there was some patchy enhancement that showed likely prior inflammatory process or replacement fibrosis. No hemodynamically significant valvular disease. So that point four, that's what's going to lead us to our conclusion on Mr. Jones. He has a dilated non-ischemic cardiomyopathy, and this was due to his anabolic steroid use. So now looking at invasive evaluation for patients with heart failure, when do we want to do a biopsy? So when you have a very specific diagnosis suspected, it's appropriate to do an endomyocardial biopsy, but it's very important to recognize that any routine use of endomyocardial biopsy will cause harm and is not indicated. On point two there, if the patient has worsening symptoms or worsening hemodynamics, it's appropriate to do invasive monitoring. This can be useful, whether it's pulmonary artery catheter or right heart catheterization. Again, that's not to be done routinely. It would be for hemodynamic compromise or severe and worsening symptoms. So when do we use endomyocardial biopsy? It's typically for our zebras, so these are the most common types of heart failure. If the patient has a pretty new onset heart failure and either the ventricle is normal sized or is dilated and they're having hemodynamic compromise, this is a more urgent situation to get to the bottom of what's happening. If they have a two-week to three-month duration of symptoms and they've got some pretty significant conduction disease and they're not responding to treatment, that can be another indication to do a biopsy. Any patient with allergic reaction with eosinophilia would be another reason you could biopsy the patient. If anthracycline is part of the history, some toxicity, or if the patient has a restrictive cardiomyopathy, if you're looking for cardiac tumors where surgical correction may be indicated, and then for your ventricular hypertrophied patients where you're suspecting infiltrative or storage diseases, and this is like your amyloid or sarcoidosis patients, biopsy may be indicated. And then for arrhythmogenic right ventricle cardiomyopathy, if you haven't had any conclusion from your other testing. So Mr. Jones continued to be symptomatic. He was hospitalized and developed acute kidney injury with diuresis and started developing diuretic resistance, and subsequently it was decided that he should undergo right heart cath. And his results showed notably cardiac index of 1.8. He had elevated filling pressures, a wedge of 19, a PAD of 33, and a pretty high SVR. So in the end, he had elevated biventricular filling pressures with decreased cardiac output. He was transferred to the ICU for medical management of his cardiogenic shock and hyperkalemia. After one year of Mr. Jones being optimized in medical therapy and undergoing resynchronization therapy for his low EF and his conduction disease, he presented back to the emergency room with class four symptoms. So he was referred for cardiopulmonary testing. So CPET can measure the oxygen uptake by looking at the peak VO2, which is a very objective assessment of the patient's functional capacity and allows us to prognosticate with our patient. A peak VO2 of less than 12 or greater than 50% predicted based on age and sex is an indication to refer the patient for cardiac transplantation. Mr. Jones underwent a CPET and his peak VO2 was 9.1. This was with a good effort demonstrated by our RER of 1.16. And his peak predicted VO2 was 34%. This puts him in a class D, Weber class D. This graph just shows what the Weber classes are based on PPO2. And you can see here at nine, he's less than 10% playing us in the severe category. So when your patient can't exercise, but you still need to evaluate their peak VO2, you can do a six minute walk. This is measuring the distance they can walk on a level surface for six minutes. And if the distance is less than 300 meters, this is associated with an increased likelihood of death or hospitalization for advanced therapies within six months. Cardiopulmonary testing that we just discussed is still considered better because it's able to carve out cardiac versus non-cardiac factors that limit the patient's exercise, but may not always be available. So to wrap up our case study based on the results of his cardiopulmonary testing, Mr. Jones was referred for advanced therapies. So when do we suspect advanced heart failure? When the patient has persistent and severe symptoms, despite being on guideline directed medical therapy. This includes device therapy, resynchronization, treatment, and that you've allowed an accurate period of time for the patient to have a response. So several months to even a year. And that you've looked at all potential reversible causes, such as arrhythmias, inflammatory processes. And at that point, you've done this, your patient is still exercise intolerant. They're having unintentional weight loss. They continue to be volume overloaded despite treatment. Recurrent ventricular arrhythmias, the blood pressure is low, and they're starting to show signs of low flow. Some objective findings, if your wedge pressure is greater than 20, right atrial pressure greater than 12, cardiac index less than 2.2, despite all optimization of your medications. And as we previously discussed, that peak VO2 of less than 12 or less than 50% of predicted VO2. If they walk less than 300 feet during, sorry, 300 meters during their six minute walk. At this point, you want to refer for evaluation and consideration of either laser dilators, inotrope therapy, mechanical circulatory support, or cardiac transplantation. So shifting gears here a little bit, at what point when we're getting our patients out of the hospital, we wanna talk a little bit about the criteria for doing this safely. As we know, our heart failure patients are very high risk for readmission, and these are very costly admissions. And each subsequent hospitalization for heart failure decreases the patient's, increases their mortality. So we wanna make sure we've identified the triggers for the hospitalization, if it was dietary or medication indiscretion that we've provided the appropriate education to our patient. We want the patient near euvolemic, we want them on oral diuretics and transitioned off all IV diuretics. We wanna make sure that the patient and the caregivers have been properly educated on what the discharge instructions are. We wanna make sure we've documented our ejection fraction during the hospitalization, provided smoking cessation when appropriate, and that guideline direct to medical therapy was initiated or optimized during the hospitalization. And if for some reason we cannot put the patient on one of the therapies, one of our four pillars that we document against this. So we couldn't put them on an ARNI because he had AKI. And we wanna make sure they have an appointment set up within seven to 10 days of hospital discharge. For our sicker patients, we wanna make sure they've been stable on their oral medications for 24 hours, no intravenous vasodilators or inotropes for the last 24 hours of hospitalization. We wanna make sure they're up and walking and we're looking at their functional capacity while on their medications and make sure there's follow-up at home. They have a scale that there's home healthcare or PT if needed, and then refer for disease management as appropriate. So do they need a sleep medicine visit, meet with nephrology, pulmonary, et cetera. Cardiac rehab's another consideration when we have our patients out of the hospital, usually involving aerobic exercise, which is where we have our highest evidence for helping patients improve, but resistance and inspiratory muscle training can also be used but are less commonly offered. For our class two to three patients with reduced ejection fraction, the indication is strong. It's a strong recommendation that we refer for cardiac rehab. For our class two to three patients with mid-range ejection fraction, the evidence is the recommendation is weaker for referral. Some benefits, we can see an improvement in their ejection fraction and also their end-diastolic and systolic volumes. Better hemodynamics, you can see a decrease in oxidative stress as well and pro-inflammatory markers. For our reduced ejection fraction, we can see overall reductions in hospitalization, improved exercise tolerance and better quality of life. Also notably, less symptoms of depression. For a mid-range and preserved ejection fraction patient, you see an improved exercise tolerance and quality of life, although a little bit less benefit than our reduced ejection fraction patients. So to conclude our assessment session here, I wanna touch on palliative care. There really are two branches to palliative care. It should be an ongoing process that really starts when you first meet the patient, assessing their symptoms and their quality of life. It can be done by both non-palliative care clinicians as well as the specialist. Your primary palliative care branch is all of the non-palliative care providers. Looking at any range of symptoms in our patients or topics from dyspnea, pain, fatigue, to mood issues, to their prognosis and what the patient's goals are for their care, making sure that everyone's involved in the decision-making as much as possible and when appropriate, discussing advanced care directives. The second palliative care branch involves our palliative care specialists. And this is when your patients are persistently in class four, NYHA class four symptoms and have comorbidities such as renal failure, COPD, dementia, metastatic cancer, et cetera. If the patient's being considered for major interventions such as an LVAD, it's also very appropriate to have the palliative care specialist meet with them first. And again, goals of care, advanced directives, very appropriate at that time. And then when the shift is, there's been an organic shift in the patient's focus to quality of life over medical management. You know, often they've been hospitalized many times and they wanna spend the rest of their time at home being as comfortable as possible. Very appropriate to have our palliative care specialist helping us with the management of this patient. So this concludes my session. Here are my references. I hope this was helpful and I wish you all the best on your exam. Thank you. Becca, very good. Thank you so much for that. We are back and we're going to ask the audience response questions again and this time have some commentary about them. Okay, I think this one was a little bit of a toss up the first time around. True or false, a Holter monitor may be ordered to a symptomatic patient when assessing for cardiac arrhythmias. I am so proud of you guys. Yeah, this is terrific. I think that this really gives an opportunity for us to think about these things. And honestly, like, I'm not sure if I think about Holter monitors as much as I should in reflecting in this moment. We see that the majority of people said that this is true and because it really is that time period when they're initiated on guideline directed medical therapy you're waiting that three months to repeat the echocardiogram. And you may be wondering, you know, do they need a life vest, you know, or can they get by without one during that time period? Really an opportunity for a Holter monitor to be helpful. Yeah, I use them a lot in my practice too because I find a lot of patients complaining, you know, they might not have palpitations but they've got a series of symptoms, just not sure what's going on. And I find that it can be really reassuring when they have that diary of, oh, I felt lightheaded or dizzy and we can reassure them there was nothing there. There's no arrhythmia that correlates. Okay, great. Well, let's move on. Okay, question two. I know this was a little tricky in the wording but I wanted to make the point to reassess the LV function. It's really only recommended when, except when the patient's clinically stable. There's no treatment that you're about to do that would impact the cardiac function. The patient is a candidate for an invasive procedure or device or you're referring for palliative care. Okay, great. So give an opportunity for a couple more people to respond. And let's go ahead and show them the results. Is this what you expected to see, Rebecca? Yep, that's what I was hoping for. So when we're planning to do something so we're referring them for device therapy, for instance, we need to know what the ejection fraction is. When they're clinically stable, we're not intending on any intervention that could impact the cardiac function, then there's no need to repeat the echo. And patients will try to push you to do this. I think we all know that. At every visit they're asking, when can I get to know my EF again? When can we check it again? So I think this is an important point to reassure them, we're gonna keep the course and until there's an intervention or something we need to do differently, there's no indication to repeat that. Okay, let's go to the next question. The following are part of a routine evaluation for new onset heart failure except, A, EKG, B, endomyocardial biopsy, C, transthoracic echo, or D, chest X-ray. Okay, we can go ahead and show them the results here. Good job, you guys. This one I think is probably a little bit of a slam dunk, but it's highlighting what is indicated, which is the EKG, transthoracic echo, and the chest X-ray. And that you can do harm to your patient doing biopsies. This is not a routine procedure. You know, this question refers to new onset heart failure. And, you know, I have a curiosity to ask both of you, I don't know if Terry or Rebecca wanna take this. Do you all have a special protocol or algorithm that you use for new onset heart failure in your clinic as far as with medical titration or with testing? I will start with this. We do not. We have certain sets for like our amyloidosis patients, but it's very specific to the physician or the provider seeing the patient as far as in the outpatient setting. As far as guideline-directed medical therapy, no, we don't have an order set for that either. We do use our heart failure pharmacists as well as our APPs as far as following guideline-directed medical therapy, but there isn't an order set per se. And I would say a little bit of the opposite. We here at Nebraska Medicine, the start of pre-COVID and then really caught on, we developed an APP-driven optimized clinic. And it was for either newly diagnosed or readmitted heart failure patients. And it was a set number of visits during which it was the APP, it's a pharmacist, it's a dietician in a multidisciplinary clinic. On their initial visit, they get screened for, do you need screening for your coronary disease? Do you need screening for sleep apnea? Do you need a screening for cardiomyems? Do we need to screen for amyloid? And we have a note and an order set. And then we also look in there and we titrate your medications and we have it protocolized to where we have so many visits. And then at the end, we've got you on appropriate medical therapy. We'll repeat your echo. We'll ensure that you see where you're going and then determine, okay, is this getting better? You continue with your regular cardiologist as it's not getting better. We're gonna refer you to EP and we're gonna refer you to heart failure. But we developed that 2018 is when we first started seeing these patients. And then when the guidelines were updated, we actually also spread this to HeffPest patients for their medical therapy. And to date have had over 1100 referrals to the clinic. Wow, that's wonderful. That's wonderful. Yeah, that sounds like an amazing program. I imagine if there's anyone who's in the audience who wants to learn more that Terry would mind. Yeah, it's my baby. I helped develop it, so. Wonderful. All right, well, let's move on to the fourth question. Okay, so question four. Which measurement should prompt evaluation for cardiac transplantation? A, peak VO2 of less than 12, B, wedge pressure greater than 16, C, right atrial pressure greater than nine or D, cardiac index less than 2.4. Okay, we can go ahead and show them those results. I think you guys are gonna do well on this exam. That was a big take home point. I hope I hit that hard in the presentation. So yeah, this is great. You guys nailed it. I think that, you know, one question I'd like to ask, and this comes back again to what comes up a lot when we're on rounds and we're teaching the medical students in residence is, you know, we have all of these patients in our outpatient clinics who have New York Heart Association class three symptoms. I mean, they all do, basically. So many of them do. And the question is how do we sort out amongst all of these patients, hundreds of patients with class three symptoms, which ones are going to progress to need advanced therapies versus those that we continue just to, you know, work with GDMT on. And I think this illustrates that so nicely that the cardiopulmonary exercise test can really help us re-stratify those patients. Absolutely, absolutely. And, you know, the six minute walk too, you know, when you need to implement that, I think that's very helpful too. But yeah, very good at differentiating, you know, and especially with the CPET, like I pointed out, it can help you carve out the non-cardiac exercises limiting factors, which I think can be very important too. And so this really is illustrating the cardiopulmonary exercise test, but could you speak to the right heart catheterization? Is the right heart catheterization something that you order in your outpatients? And if so, when might you order one? So, yeah, that's a great question. So I would say, and this is how I usually phrase it to patients when we're just puzzled, when we're just having a hard time figuring out, are you really volume up or is this something else? And especially when AKI becomes part of the picture, we're seeing some diuretic resistance. Yeah, especially when the patients are really symptomatic and it just doesn't, things aren't matching up. That's typically when we'll reach for the right heart cath or if they're starting to show you signs of low flow. So, you know, a lot of patients having a lot of GI symptoms, increased fatigue, increased dyspnea, just not sure what's going on, how much of this is volume versus maybe they are low flow, then we reach for the right heart cath. And understanding, you know, the outcome, and I think this is probably true of your facilities too, that if the right heart cath is not favorable, that gets them to the ICU and gets a medical optimization, you know, pretty expedited, as opposed to what we can do in the outpatient world. Now, meanwhile, in the chat, we have a lot of people who are interested in the optimized clinic. And so I wonder, Terry, if, you know, back to the Heart Failure Society of America Education Committee, that we need to maybe propose one of our next heart failure seminars on outpatient optimization. Yeah. I saw a couple of those, and I don't know if someone from heart failure can get their emails. I'm willing to share what we have. We actually, I think it was, I can't remember, my year is coming by, but we published our, it was published in 2022. We published our data in the Journal of Cardiac Failure, which is the American Association of Heart Failure Nurses Journal, but I'm happy to share any protocols with anyone that wants them, if I can just get their emails, whether they want to send them through this or HFSA can, if I can, I can give them to the HFSA and they can give them to the people registered too. That's a great idea. So a question from Scott, do we use the same VO2 criteria for mechanical support patients, or would we consider them a higher VO2? I think in our institution, at least at 12, if they're going to be a candidate for transplantation, we're looking at that, but if not then mechanical circulatory support. So yeah, I would say no, they're pretty equal. I feel like don't the like Medicare, Medicaid guidelines say that you can have a VO2 up to 14 for an LVAD though? I don't think this is a question on the test, but I feel like when we review them at PSC, like for LVAD, especially as a DT LVAD, and I don't know if that's still a thing in your state, but I live in Nebraska, so Nebraska Medicaid will cover it, but Iowa Medicaid will not cover a DT LVAD. And the cutoff for those is specifically less than 14. Okay, that's good to know. And he's saying 14 is what he remembered. Yeah. Yeah. So yeah, maybe that is a bit dependent on your location. So question from Diane, can you go over the EKG based on the comment that consistent with the dilated cardiomyopathy, that the EKG was consistent with the dilated cardiomyopathy in your presentation, Rebecca? As well as could you comment on the pathophysiology of the patchy findings on the MR with anabolic steroids? Okay, so I don't know, we can't pull up that slide, can we, with the EKG? I'm seeing if I have it here, bear with me. Okay, so what is the question about the EKG as far as the dilated cardiomyopathy? Yeah, so what was it about the EKG that made it be consistent with the dilated cardiomyopathy? That you had ST segment changes, and that the QRS was prolonged at 158, and he didn't end up needing a CRT for this. Okay, yeah, and it was mentioned here that also with the absence of ischemic changes or QAs across the myocardium makes it more likely a dilated cardiomyopathy. Correct, yeah, and he was not ischemic as we know. And you pulled this up too. And then the MRI, is that something that you consistently see in the MRI? Let's go to the MRI findings. You know, I'll be honest, we don't see a lot of anabolic steroid abuse as etiology of cardiac MRI, which I think makes this case interesting. I don't know, Terry, if you see a lot of it where you are. So- Not a ton, but- Yeah, that's definitely more of a zebra where I practice. So I'm not sure what the exact question was on that. I'm sorry. Just whether that's classic for steroid-induced myocarditis. I'm not sure about that either. I believe from what I looked at it is, but yeah, I don't see a lot of that. Okay. In our institution, we use cardiac MRI a lot for infiltrative and restrictive cardiomyopathies. You know, when we really can't figure out what's going on or we just haven't gotten to the bottom of it. If they're not ischemic, the history isn't pointing to one etiology over another. Then we start looking for these restrictive or infiltrative diseases. And they're very helpful. Well, I can't believe it, but we are at end of time. And so that went so quickly, didn't it? So let's go ahead and take down these slides and put the conclusion slides up. And just as a reminder to everyone, we have one more installment of the bootcamp coming. And so we will make sure that we pick up anything we missed in the chat in our final installment. A few things, housekeeping as we wrap up, we will see you all on July 25th, where we'll be talking about management. Part one and part two, we'll really be talking a lot about guideline-directed medical therapy. We have two phenomenal form Ds who are gonna be sharing with us and we'll be able to get a little bit into both initiation of treatment. I know that was a question we didn't get to today, initiation of treatment and also encouragement of patients for treatment. Next slide, please. We also had questions about the first heart failure CERT cohort. So the first exam window was from January 9th to March 10th of 2023. Of course, the next testing window is coming up August to September of this year. We had 82 test takers and we have the provider breakdown here. So over half were nurses. We don't have an assessment of how many were RNs versus NPs, but otherwise we have 1% physician assistants, 9% pharmacists and 27% physicians, 9% were other, and the exam pass rate was 95%. So in follow-up, so you will be receiving a survey by email after this webinar and we will be using the feedback you give us to improve our third installment. So please participate in that. The Zoom link for the next webinar will be sent to you the day before July 25th and please feel free to visit the Heart Failure CERT virtual bootcamp to view the next webinar's agenda and the faculty. And finally is our Heart Failure Certification website. This is where you can sign up to take the exam and also review all of the subject material that is included in the exam that was used to build the review didactic lectures that you're seeing in the bootcamp and also a list of the references that Terri referred to as how she prepped for her exam. And with that, I'll conclude for this evening. Thank you all so much for your attention. Thank you so much to our speakers. You guys did a phenomenal job and we look forward to seeing everybody on the 25th. Good night, everyone, and good luck. And good luck.

Heart Failure Certification Bootcamp

Jennifer Cook

Education Committee

Heart Failure Society of America

Assessment of heart failure patients

Terry Dedrick

Rebecca Ray

Clinical history

Physical examination

Laboratory testing

Diagnostic tools

Risk assessment models

Nutritional deficiencies