Hello, everybody. Welcome to our session titled, What You Need to Know Stats, HF STATS. I'm Bikram Bhaskar, the chair of the Data in Heart Failure Committee and the HF STATS Writing Group. And I would like to welcome my co-chair of this session, Dr. Robert Page, Professor in Departments of Clinical Pharmacy and Physical Medicine at the University of Colorado. Welcome, Dr. Page. Thank you so much, Dr. Bhaskar. It's a pleasure. Thank you. And our panelists, which include Cynthia Chohan, our patient advocate and patient representative. Welcome, Ms. Chohan. Oh, thank you. I'm so happy to be here. Dr. Mike Felker, Professor of Medicine in the Division of Cardiology at Duke University Medical Center and the President of the HFSA. Welcome, Dr. Felker. Hello, everybody. It's a pleasure to be here. Dr. Eileen Hisch, Professor of Medicine at Cleveland Clinic. Welcome, Dr. Hisch. Thank you. Excited to be here. And Dr. Colleen McAlvin, Associate Professor in the Division of Cardiology at the University of Colorado School of Medicine. Welcome, Dr. McAlvin. Thank you so much. Thanks for having me. And if I could have the next slide. A few words about HF STATS. HF STATS is an initiative commissioned by the Heart Failure Society of America and spearheaded by the Data in Heart Failure Committee. The purpose of the HF STATS is to synthesize and summarize the trends in epidemiology and outcomes in heart failure. If I could have the next slide. Highlighting the concerning trends in the incidence, prevalence, lifetime risk, mortality, and hospitalization rates of heart failure. The first report of HF STATS was published in 2023 and an update was published in September of 2024. In this session, if I could have the next slide, we will cover important trends in incidence and prevalence, which will be covered by Dr. McAlvin and trends in mortality, which will be presented by me, trends in hospitalization and treatment by Dr. Page, and the top 10 takeaways again by me. And Dr. Falker will present an overview of the strategies by the HF STATS to close the gaps. And we will conclude by a panel discussion that will be moderated by Dr. Hish and our patient representative, Ms. Chohan. And we expect to have a wonderful discussion with all our participants and look forward to hearing from you. And if you have any questions, feel free to enter them in the chat. With that, I would like to invite Colleen for the first presentation on the trends in incidence and prevalence of heart failure. Colleen? Thank you so much. I just want to say again, thank you to HFSA and the organizers for having me here today. We're really discussing an important document that represents the most updated data we have in heart failure. And I'm going to start us off by talking about the trends, incidence and prevalence and lifetime risk estimates of heart failure. The lifetime risk of heart failure, as you can see in this figure, is one in four or about 24% over a person's lifetime. This is important because it's increased from one in five individuals from previous Framingham study cohorts. In other cohorts, such as those enrolled in the MESA study and cardiovascular health study, the lifetime risk range from 23% in women to 27% in men. Overall, the lifetime risk is high and it varies by sex, race, and ethnicity, which we'll discuss over the next few slides. We also know that the risk of developing heart failure continues to rise among individuals with obesity and hypertension. Next slide. Just a little background on incidence of heart failure. The incidence of heart failure varies according to differences in population demographics and composition, including age, comorbidities, sex, race, and ethnicity, heart failure, ascertainment methodology, and timeframe. Some of the variations in the overall incidence and prevalence of heart failure across different studies can also be explained by the increasing representation of HEF-PEF in different populations. The rise in HEF-PEF prevalence can be attributed to increasing clusters of risk factors, such as obesity, metabolic syndrome, diabetes, CKD, along with increased awareness and utilization of diagnostic strategies for HEF-PEF. The next few slides will describe incidence data stratified by age, sex, race, and ethnicity. Next slide. So the distributions of heart failure etiologies vary between women and men and across age groups, which is seen in this figure here. To orient you, you can see the etiologies color-coded on the right and the proportional representation on the left. So the black bars represent congenital heart disease, which is the primary etiology among individuals younger than 20 years of age in both sexes. The proportion of heart failure attributed to ischemic disease is represented by the red bars and increases in age in both sexes, with a higher proportion of males having heart failure compared to females. Last, hypertensive heart disease is the predominant cause of heart failure in females, peaking in the 40 to 49 age group, and this difference remains significant until age 80 when it is surpassed by ischemic heart disease. Next slide. Importantly, the incidence of heart failure varies according to race and ethnicity. Specifically, the incidence of heart failure is higher among black individuals compared to other racial and ethnic groups. In the MESA study, black individuals had the highest heart failure incidence rate of 4.6 per 1,000 person-years. You can see represented by the red bar here. Hispanic, white, and Chinese individuals had incident rates of 3.5, 2.4, and 1.0 per 1,000 person-years, respectively. Similarly, in the ERIC cohort, the incidence of heart failure was significantly higher among black individuals, 17.2 and 19.0 per 1,000 person-years of black women and men, respectively, when compared to white individuals. Next slide. So I'm going to spend the rest of my time discussing prevalence. This figure here, I think, is a really important one to pay attention to. Approximately 6.7 million Americans over 20 years of age have heart failure, and the prevalence is expected to rise to 8.5 million Americans in 2030, 10.3 million in 2040, and 11.4 million Americans by 2050. The aging of the population is a major contributor to the expected prevalence of heart failure. In addition, the impact of increasing and clustering of risk factors and comorbidities in heart failure, disparities, inequities, and barriers to access in health care, COVID-19, and other environmental factors such as air pollution and cardiac toxins, and the enhanced ability to detect and diagnose heart failure may further increase the burden of heart failure. Next slide. Similar to the U.S., heart failure prevalence is increasing globally, but heart failure incidence, prevalence, etiology, and outcomes vary widely between different regions. Heart failure prevalence estimates around the world range from 1 to 3 percent of the overall population. The next few slides will describe the prevalence in relation to age, sex, race, ethnicity, geography, and heart failure stages. Next slide. Globally, heart failure is most prevalent among adults age greater than or equal to age 60 years of age. The risk of developing heart failure is 20-fold higher among adults greater than 60 years of age compared to those under age 60. The next two figures show the current estimates and trends of heart failure prevalence in the U.S. by categories. So, the slide that you're seeing right now shows the observed prevalence proportion of those with heart failure within age groups ranging from 0.35 percent in those 20 to 39 years and older to greater than 10 percent in those 80 years and older. Next slide. This figure shows the trends in heart failure prevalence in the U.S. by age categories. Based on the NHANES data from 2011 to 2012 to 2017 to 2020, there was a downward trend in the prevalence of heart failure over time among adults aged 80 years and older, as well as among those aged 70 to 79 years and older. Those are represented by the red and blue lines. However, increases in prevalence were noted among younger age groups, specifically adults aged 20 to 39, 40 to 59, and 60 to 69 years, which had the highest increases since 2016. Those are represented by the purple, gray, and yellow lines, respectively. Next slide. According to the NHANES data, heart failure prevalence has increased from 1999 to 2004, both in women and in men. The prevalence of heart failure varies across age groups, showing lower rates in women compared to men between the ages of 40 to 59, 1.2 percent in women versus 2.3 percent in men, and ages 60 to 79, where the representation was 4.2 percent in women versus 7.5 percent in men. However, the prevalence is higher in women ages greater than 80 years of old or older, so 10.9 percent in women versus 7.15 percent in men. Approximately three million adult women in the U.S. aged 20 and older have heart failure, constituting approximately 44 percent of the adult population. Overall, the prevalence of heart failure among women is 1.9 percent, while among men is 2.7 percent. Next slide. According to global burden of disease data spanning 204 countries and territories from 1990 to 2019, out of 56 million people living with heart failure in 2019, over 50 percent were females. From this figure, you can see age-standardized heart failure prevalence with males on the left and females on the right. Age-standardized prevalence was higher in males in high-income countries with ischemic heart disease and hypertensive heart disease leading causes of heart failure in both males and females, respectively. Next slide. Heart failure is more prevalent among younger and middle-aged black adults aged 35 to 64 years, compared with younger and middle-aged white adults. From this figure, you can see that according to NHANES data spanning 2001 to 2016, the prevalence of heart failure was highest for non-Hispanic black individuals, followed by non-Hispanic white and Mexican-American individuals. This is consistent with participants of the ERIC study above the age of 55 years, in which the age-adjusted prevalence of heart failure was higher among black women and black men compared to white men and white women from 2005 to 2014. Next slide. Within the U.S., there are geographic variations in the prevalence of heart failure, as you can see here. A low heart failure prevalence has been reported in the northern Great Plains and western states, represented by shades of blue and green, and the highest prevalence of heart failure has been reported in the western and eastern states, represented by shades of orange and red. Next slide. The last stratification is by across heart failure stages, and data remains limited regarding the prevalence of heart failure stratified by these stages, with at-risk for heart failure as stage A, pre-heart failure stage B, clinical heart failure stage C, and advanced heart failure stage D. Additionally, the criteria and definitions of heart failure stages are evolving, further adding complexity to prevalence estimates by heart failure stages. In a study from Olmstead County between 1997 and 2000, among participants aged greater than or equal to 40 years old, the prevalence of stage A was 22 percent, stage B was 34 percent, stage C was 12 percent, and stage D was 0.2 percent. Among older patients aged 67 and 91 years from the ERIC study, 52 percent had stage A, 30 percent had stage B, and 13 percent had stage C, with only 5 percent of participants being without heart failure risk factors or structural heart disease. And last, in the Framingham Heart Study, which had a mean age of 51 years, the prevalence of stage A heart failure was 36 percent, stage B was 24 percent, and stages C and D were 1.2 percent. In the bottom half of this figure, you can see a pooled analysis from MESA, the Cardiovascular Health Study, and Framingham cohorts using the 2022 updated ACC HFSA definitions of heart failure stages. That definition incorporates elevation and cardiac biomarkers to help classify pre-heart failure, or stage B, and ultimately identified 37 percent with stage A, 43 percent with stage B, and 2.7 with stage C and D heart failure. Now I'd like to turn it over to Dr. Bozkurt, who will be discussing the current trends in mortality related to heart failure. Thank you, Colleen. If I could have the next slide. These are my disclosures. We want to alert the heart failure and cardiovascular community that in the U.S., mortality related to heart failure has been steadily increasing since 2012. As seen on this slide, it accelerated during the COVID pandemic years between 2020 and 2022, but importantly, it continues to rise compared to the nadir that we saw back in 2012. Next slide. And these sobering results are not only seen among older individuals, but also in younger populations, as shown on this slide, between the ages of 25 to 34. Next slide. Between ages 35 to 44. Next slide. Or 45 to 54. These trends are quite concerning, reflecting the fact that heart failure is not only a problem for older populations, and mortality is seen also in younger populations and is steadily increasing. Next slide. We also see a mortality rate increase among individuals between the ages of 55 and 64, but as seen on this slide, we had seen the decline until 2012, and then the rise since 2012 for the older populations, as seen on this slide, for the ages between 65 and 74. For younger populations, initially until 2012, we had a flat rate of mortality, and then an increase since 2012. If we can look at the older populations, as seen in the next slide, if we could have the next slide, between ages 75 and 84. And next slide. Ages over 85, we again see that U-shaped curve of the initial decline until 2012, and a steady increase since 2012 for mortality rates. But as you could see, in older populations, the overall increase seems to be less steeper than what we are seeing in the younger populations. Next slide. All cause mortality rates related to heart failure are usually higher in men compared to women, and as seen on this slide, mortality rates have been increasing similarly for men as well as women since 2012. Next slide. It should have ever been noted that though overall mortality rates are higher in men, in hospitalized patients, once patients are hospitalized, the mortality rates following hospitalization are very similar in both men and women across all heart failure phenotypes. So post-hospitalization, mortality rates are as high in women as in men. Next slide. And women with heart failure have excess life years lost after index hospitalization than men when compared to the median sex and age-specific U.S. life expectancy for all EF phenotypes. Women lose approximately three more years than men, both in heart failure with reduced EF, mildly reduced EF, as well as preserved EF. Next slide. This is despite the proven benefit from treatment modalities in women, women benefiting from all heart failure therapies, including guideline-directed medical therapies, device therapies, as well as advanced therapies, such as ventricular assist device or cardiac transplantation, as shown on this slide, demonstrating that there is very similar post-cardiac transplantation graft survival in women to men. Despite all the evidence of equal benefit, women are referred less to advanced therapies and GDMT use, guideline-directed medical therapy use, is less in women than in men. Next slide. There are very concerning trends in mortality rates according to race and ethnicity. Black patients have the highest mortality rates compared to any other race, and their mortality rates have been steadily increasing since 2019 and have accelerated since COVID. Next slide. We also recognize significant adverse trends in rural locations. Mortality rates are significantly higher in rural compared to urban locations, and the mortality rates related to heart failure have been steadily increasing in both. Next slide. The mortality rates related to heart failure are highest in some of the southern and southeastern states, such as Louisiana, Mississippi, Alabama, Arkansas, when we just look at the states, states themselves. Next slide. But interestingly, in the CDC heat maps, there are other trends that are becoming very discernible. Especially in Midwest, rural zip codes have higher mortality rates related to heart failure, raising concerns for inequities for access and for treatment of heart failure. Thus, this heat map represents rural areas have higher mortality rates, especially in certain zip codes than other areas. And it is not solely southern states, but also Midwest that is showing higher mortality rates. Next slide. Adverse trends in increasing mortality rates since 2012 are noted for all regions in the United States. But if you were to look at the differences between different regions, the mortality rates now are the highest in Midwest, followed by southern regions, and the increases in Midwest and southern regions are steeper than the mortality rates in Northeast. Next slide. The mortality rates related to heart failure, even in younger populations, as shown in this slide, between the ages of 15 and 44, are higher in non-metropolitan, predominantly rural areas, and have been steadily increasing in a steeper fashion than metropolitan areas. Next slide. Regarding mortality rates according to ejection fraction phenotypes in hospitalized patients, five-year mortality rates are very similar post-discharge in patients with heart failure with reduced EF, mildly reduced EF, and preserved EF, underscoring the poor prognosis amongst hospitalized heart failure patients, regardless of the EF phenotype. So keep in mind, once hospitalized, mortality rates are very similar across all EF phenotypes. Next slide. But in non-hospitalized patients, if we look at the overall heart failure community, as represented on this slide with registries with chronic heart failure patients, heart failure patients usually have higher mortality rates for the reduced EF phenotype. The mortality rates are highest for HF-REF, followed by mildly reduced EF, and then preserved EF have lower mortality rates for reduced EF for chronic ambulatory heart failure patients. Next slide. It should be also noted that cause of death differs significantly between EF phenotypes. In patients with heart failure with reduced EF, a higher proportion of patients die from cardiovascular death, whereas in patients with heart failure with preserved EF, a higher proportion of patients die from non-cardiovascular death. Next slide. Thus, as left ventricular ejection fraction increases, rates of death attributed to sudden cardiac death, represented by the red, and heart failure death, represented by the blue decrease, and the non-cardiovascular death, represented by purple color increase. These underscore the recognition of differences in causes of mortality in patients with heart failure with reduced EF versus preserved EF. Now we will move on to the next topic, which will be presented by Dr. Robert Page, and he will review the current trends in hospitalization rates and treatment of heart failure. Robert? Thank you so much, Dr. Bozkurt. Again, I'm going to, over the next couple of slides, I'm gonna highlight some of the current trends in hospitalization rates, and I'm gonna add to some of the data from Dr. McAvenin, as well as Dr. Bozkurt, and then we're gonna show a little bit about with regards to treatment of heart failure. Next slide. Alrighty. Thank you so much. Why is hospitalization so very important? Just as Dr. Bozkurt mentioned, is the fact that number one, it's tied to mortality. Number two, it's tied to an increased cost. And number three, we're evaluated based upon the length of stay, as well as number of patients who were admitted. These data right here are basically looking at U.S. trends for overall heart failure hospitalizations, unique patient stays, post-discharge heart failure readmissions, and all-cause 30-day readmissions. What you're looking at is the absolute number of hospitalizations per year. And again, I want you to focus in primarily upon the red, which is going to be primary or secondary heart failure hospitalizations, and then also in the blue, which is non-heart failure hospitalizations. All in all, these data were derived from the Nationwide Readmissions Dataset, which was a very robust dataset of hospital admissions for heart failure. As you can see here, we started to actually see an increase in from 2014 to 2021. We went, if you look at the red bars, again, we're a little in about 4 million, that in 2010, all the way up to well above 5 million by 2021. We did see a decline between 2019 and 2020 due to COVID. Next slide. These are data that were derived initially from the National Inpatient Sample, and they're also going to complement Dr. Boskirk's mortality data as well. These data are between 2004 to 2018, stratified based on age, sex, race, ethnicity, and rural location. As you can see here on these slides, heart failure has been increasing across both sex and age since 2013. You'll notice this 2013 comes up a lot. Something did happen in that time, because after that, we started to see a slight bump. The other aspect, which is not shown here, while we're seeing an increase in hospitalization, we're also seeing a decrease, however, with regards to inpatient mortality. As Dr. McElvenin mentioned, Blacks, African-Americans basically had an increase in hospitalizations, while white patients had a higher increase in hospital mortality. Next slide. What I like about this slide and about these data is that it's capturing some of our most vulnerable population, which are our octogenarians. These are data derived from the National Inpatient Sample. This is a 15-year national data set. What it suggests is that despite having a higher comorbidity burden within these older adults and with an increase in hospitalization since 2013, what's interesting is, I'm going to add these data to Dr. McElvenin's, we're also seeing a trend, believe it or not, towards lower inpatient mortality, which you're looking at here on this slide, again, just to highlight is primary heart failure hospitalizations per 100,000 age in these older adults. Next slide. These data may look a little bit similar to Dr. Boskirk's, but these are data that were derived from Get With The Guidelines Heart Failure Registry, capturing data between 2006 to 2013. They're also stratified based upon the effect modification of heart failure phenotype. Overall, over the five-year follow-up period, you can see here that both males and females had overall a poor survival post-discharge. However, as Dr. Boskirk mentioned, females had greater years of survival lost due to heart failure when you compare this cohort to a matched median age and estimated, or excuse me, to median age in sex that were matched based with the U.S. population. If you look over to the far right, however, in terms of readmissions, and again, this is five-year heart failure hospitalization, and you'll see that the highest amount is going to be females with that of HFREF, while the lowest will be males with HFPEF. Next slide. In terms of annual heart failure hospitalization volumes, these are data that are derived from the National Inpatient Sample, and they are stratified based upon HFREF, PEF, and then unspecified. As you can see here, between 2008 to 2018, we have seen a rise in terms of HFREF, and also a steady rise with regards to HFPEF in terms of hospitalization. Meanwhile, however, we're seeing a decrease in unspecified. I think this has a great thing to do with regards to ICD-10 codes and being a lot more specific so we can narrow that down. Next slide. Again, these are data from Dr. Fonaro's database with regards to Get With The Guidelines Heart Failure Registry. These actually included a total in of about 559,000 patients with heart failure between 2014 to 2016. And what we find from these datasets is that about 45% had HFREF, of which the majority, between eight, nine percent or so, had an EF between 16 to 25. In terms of heart failure or HFMREF, again, it was about 14% of patients in which the majority were between 46 to 50%. For HFPEF, it was 41% of heart failure patients with the largest amount having an EF between 56 to 60. Next slide. These data represent, these actually come out from Dr. Dunlay. And in her analysis, what these investigators did is they looked at the Olmstead County dataset between 2007 to 2017, and looking, evaluating the cumulative mean hospitalization stratified based upon heart failure phenotype. And as you can see here, in terms of the cumulative hospitalization, we're seeing a rise in almost all three. Next. I get real excited about these data because these refer to advanced therapies. And I'm at a center currently right now where we used to do 20 heart transplants, and now we're almost up to 80 per year. And these data reflect that. Between 2013 to 2023, overall, what is in red is looking at total heart transplants. What's in blue is stratified by DBD, and what's in yellow is stratified by DCD. What's in yellow is stratified by DCD. And then what's in gray is your durable medical devices like your LVAD. What we're seeing here is a really robust trend in terms of the number of overall transplants going from just starting at 2,500, and now we're almost up to 5,000. And again, this is very exciting data as we're giving patients a second chance at life. Next slide. These data also coming from the Scientific Registry of Transplant Recipients. These are what is in red is heart kidney, blue heart liver, and then what is in yellow is heart lung. And as you can see, again, it's very exciting data. If you look at the magnitude of change in terms of an increase, it is pretty much, again, steadily increasing. Where we're still kind of hung up is, again, primarily with heart lung. Those numbers have remained below 50. Next slide. No surprise, and again, being a Southerner myself who trained in South Carolina, it makes sense if you look at the hospital discharges for HFREF and HFPEF stratified by region. You'll see here this is in terms of all comers in terms of heart failure, and then HFREF and HFPEF. Regardless of stratification based on phenotype, again, the South is having the highest amount of heart failure discharges. Next. But what about from a global perspective? And what's really unique, again, about these data is that this combines many different registries from European nations, China, Japan, Haiti, and again, these are data that are stratified based upon prevalence of heart failure by EF among different populations, again. So as you can imagine, in terms of HFREF, we see anywhere between about a 36 to a 71% in terms of prevalence, and then again, a much smaller in terms of mid-range ejection fraction, and then again, a very wide variability with regards to preserved ejection fraction, anywhere between 16.2% and as high as 43% in Japan. This may be due to the fact that patients within Japan tend to also live longer, therefore will have more HF. Next slide. These are data just to add to Dr. Boskirk's earlier presentation, the absolute deaths and age-adjusted mortality rates for heart failure are stratified by sex. And what I really wanted you to focus in upon is the top portion. You're looking here at absolute deaths as well as age-adjusted mortality rates between 2018 to 2022. And what we're really observing here, unfortunately, is that we've seen in males the steady increase in their overall AAMR. And the same thing goes with females, but it's not as dramatic in terms of the magnitude. In terms of cardiovascular deaths related to heart failure, these have been based, stratified based on male or female. You'll notice that these numbers stay somewhat consistent between 69.4 to that of 72.8 over the time period. And as well as for female, 49.6 to the highest as being 53.4. Next slide. These data are also in terms looking at age-adjusted mortality rates per 100,000. And again, these are individuals who are greater than 25 years or older. These are stratified also based upon ethnicity. And what I want you to focus in upon is that heart failure age-adjusted mortality rates per 100,000. It doesn't matter across the board, as Dr. Boskirk mentioned, in terms of every ethnic class had basically an overall increase between 2010 to 2023 with the exception of non-Hispanic American Indian or native Alaskan natives. Next slide. If we break these down by age, in terms of hospitalization, you'll notice that in terms of, for HFREF and HFPEF, it's going to be around 74 to 78 years of age. What I really am impressed with is this in-hospital mortality. And as you notice across the majority of age groups, beginning with age 35 to 44, we're seeing actually a decrease in this in-hospital mortality, 1.5 to one. For greater than 75, 5.8 to 3.8%. So we are seeing this drop. What do I attribute this to? I attribute this to the ability of many health systems implementing GDMT within the hospital setting. So they're getting it before discharge. So again, very, very powerful data. Next slide. This is also looking at heart failure hospitalization rates among Medicare beneficiaries, 65 years of age per 1,000 beneficiaries. And again, these data come from the CDC. I think what's real exciting is across the board, if you compare data from 2005 to 2007 to 2019 to 2021, across the board, regardless of ethnicity, you're seeing a drop. And I think that is quite comforting that we're heading in the right directions. But nonetheless, you can see that there were, in terms of all races, it was 15.3 per 1,000 non-Hispanic blacks, 25.8, again, still the highest as Dr. McElvenin and Dr. Boskirk have mentioned, 14.6 for non-Hispanic white and then 14.5 for Hispanic. Next slide. I'm gonna focus in, this is a very comprehensive slide. Again, I'm a pharmacist. So I focus in on GDMT. What I really want you to look at, and what's in here is looking at percentage of patients from treatments and percentage of patients receiving specific guideline-directed medical therapy, but it also takes into account various registries, but also studies as well. Focus in upon the Evolution HF study, which I believe Dr. Boskirk, you were involved in. This particular, this evaluation, this registry contained, it was multinational. And so it's quite powerful from that standpoint. What I wanna highlight is, is if you compare to like the 2017 or 2013 from other areas, we're seeing a very good uptake in terms of ARNI at 73%, with regards to beta blocker at 75% and 77% with the SGLT2s. The one thing, caveat I wanna focus in on is if you look at the bottom of the slide, look at the percentage at target dose. What still scares me, after 30 years of data with beta blockers, only 7% within that study were at their target beta blocker dose, which we know increases their left ventricular ejection fraction as well as reduces their mortality based upon the MOCA data with Carbetalol. But nonetheless, again, there's definitely, what this shows us is there are some areas for improvement. Next slide. Now, I do wanna highlight, I apologize in terms of the dates up here, this should be 2020, 2021 and 2022, not 2010, 2011 and 2012. But what this is actually, what these data are looking at is adherence to quality measures in the Get With The Guidelines program between this index time period. What we're seeing here, I think, is the impact of many different things. Number one is clinical inertia. Number two, to quote Dr. Stephen Green from Duke, he always talks about errors of omission, and I think that's obvious here as well. Where it comes down to is primarily going to be with regards to where we're seeing holes, initiation of ARNI, initiation of an SGLT2, follow up with regards to an MRA, and then also getting someone started on an MRA, and then also looking at devices like CRT. So again, these data show that we have some areas for improvement, okay? And with that, I am going to turn this over to Dr. Boskirk, who's gonna bring us home with the last 10 things you need to know summary. Thank you, Robert. Before I start summarizing the top things to know, I would like to welcome our participants to pose any questions they may have in the Q&A button on the bottom of your screen. Our panel members will try to address that before our discussion, and we welcome you to pose your questions, and we will try to address them during the panel discussion timeframe. So regarding the top things to know from this presentation, number one, a large proportion of our U.S. population have heart failure. If one needs to remember these specific numbers, currently it's approximated approximately 6.7 million Americans over the age of 20 having heart failure. The prevalence is expected to increase to approximately 10 million in 2040, and 11 million by 2050. The lifetime risk of heart failure has increased. Approximately one in four individuals will develop heart failure in their lifetime. Proportion of younger patients with heart failure is increasing compared to the proportion of older patients. Approximately one third of the adult population in the U.S. has risk factors for heart failure, even though they do not have the diagnosis of heart failure, and we call that stage A, or at risk for heart failure. Approximately 24 to 34% of the U.S. population has pre-heart failure, a stage which we consider to have a higher risk future than just having risk factors, and is usually accompanied with structural changes or biomarker changes, even if the individuals don't currently have any symptoms or signs of heart failure. The risk of heart failure is increasing over time, and this is due to the increasing clusters of risk, especially with increasing rates of obesity, hypertension, chronic kidney disease, atrial fibrillation, and other comorbidities. Next slide. The incidence and prevalence of heart failure is higher among Black individuals compared to other racial or ethnic groups. The prevalence of heart failure has increased among Black and Hispanic individuals over time. The heart failure mortality rates have been increasing since 2012, with a more pronounced acceleration during the time of COVID between 2012 and 2020. And 2021, but it continues to increase even post-COVID. Heart failure accounted for 45% of the cardiovascular deaths in the U.S. in 2021. Black, American Indian, and Alaska Native individuals have the highest all-cause age-adjusted heart failure mortality rates compared with other racial or ethnic groups. From 2010 to 2020, heart failure mortality rates have increased for Black individuals at a rate higher than any other racial or ethnic group, particularly for individuals with age less than 65. Next slide. A greater relative annual increase in heart failure mortality rates have been noted for younger individuals between the ages of 35 to 64 compared with older individuals over age 65. Highest heart failure death rates have been reported in Midwest, Southeast, and Southern states. Rural areas demonstrate higher heart failure mortality rates for both younger and older age groups compared with urban areas. Rates of heart failure hospitalizations have increased since 2014. Despite a transient drop during the time of COVID between 2020 and 2022, this increase was consistent between age groups and sexes with the highest hospitalization rates being among Black patients. These summary points we hope will be helpful to you for recognition of the current gaps in heart failure care and the adverse trends in mortality and hospitalization rates. With that, I will now turn it over to Dr. Mike Felker, the current president of the HFSA, who will be talking about the strategies by HFSA to close the gap. Mike? Thank you so much, Beakam. And again, it's a pleasure to join everyone for this really important review of these epidemiologic data. You can go to the next slide. So I was asked to talk about what is HFSA doing to try to close the gap. And certainly, there's been some sobering data presented over the last 45 minutes or so about gaps and changes and outcomes for our patients with heart failure. And really, I think what we've discussed really points to a major paradox, which I'll just try to recap. And that is that we are seeing these increases in mortality over the last 10 years or so. And those are present across racial and ethnic groups and age groups and geographies, although certainly we see more severe concerning trends among certain groups in rural Americans, in black Americans, in younger patients. But what the paradox is that this is occurring at the same time that we actually have more advances in the therapy for heart failure than we've ever had before. So that really, I think, is the need for a reassessment of what we're doing as clinicians taking care of these patients and what we're doing as a society to try to address this trend. And we talk about gaps. We often talk about gaps in outcome, but of course, there's also gaps in treatment. If you can go to the next slide. And this is a slide that's been shown many times by one of my colleagues, Duke Steve Green from the CHAMP-HF Registry. And these data now are about six years old, but really they show, even in eligible patients, a very large gap in treatment, even for drugs that we know work. They tend to be underutilized, and in some cases, vastly underutilized. And you might look at data like this and think, well, some of these drugs had just come out, for example, like Arnie's Secubitrival Sardin had just only recently come onto the market, and so it takes some time for there to be uptake. And while that's true, there was just a publication in JAMA Cardiology within the last month showing that even seven years after the approval of Secubitrival Sardin, only about half of eligible patients were being discharged from the hospital on that medication despite the data supporting its efficacy. So, we have this paradox where we have worsening outcomes, we have a lot of effective therapies, but we have persistent gaps in how those are used. So, if you can go to the next slide, I'm just gonna talk briefly about what HFSA is doing to try to address some of these gaps, and I certainly won't be able to cover everything HFSA does in just a few minutes, but I just wanna try to touch on some highlights. And so, I'll start with the vision and mission statement of HFSA. Really, HFSA, its goal is to create a world of healthier lives for those touched by heart failure. And I'll note that that includes patients, but also family members and caregivers and communities, all of whom are touched by the experience of having a loved one or family member with heart failure. And so, HFSA wants to improve the lives affected by heart failure through a combination of activities around education, around collaboration and innovation, and I'll try to touch on a few of those in the next few slides. So, I'll start with education. Education is foundational to what HFSA does, and the foundation of our educational efforts is the annual scientific meeting. Of course, we were not able to gather together in person in Atlanta in September due to the hurricane, but we really are excited about gathering in Minneapolis in 2025, where I'm assured a hurricane is extremely unlikely. But the scientific meeting, although it's a prominent part of what HFSA does, is only a small part of our educational activities. These include scientific statements and guidelines, some very comprehensive educational programs, HF-CERT and OMT-CERT, which are different programs designed for learners at different stages in their career and their heart failure journey. We do HF seminars, which are web-based events like tonight, to try to bring data to people and update them on things going on in heart failure. We have the Heart Failure Board Review Course. We have a whole number of ongoing educational activities, podcasts, CardioBytes, which are very short educational YouTube videos, and these are all very accessible to people. You can listen to it while you go on a jog or in your car. And of course, we have a wide variety of endorsed educational programs at the local level. So really, HFSA just has an incredible smorgasbord of educational activities, more than any person could really take advantage of by themselves, but a critical part of the HFSA mission. Next slide. HFSA is engaged in research, really not just in collaboration around research, but increasingly around funding of research with the launch of the Heart Failure Research Foundation, where we're launching actual grants where HFSA will fund for young investigators. Of course, the Journal of Cardiac Failure is a central and really growing and thriving part of the HFSA research mission as it presents new data to the heart failure community, and we've been extremely excited about the growth and success of JCF, HF Research Network, which is involved in organizing and collaborating around ongoing clinical trials. Of course, we present the latest research information through scientific statements, through guidelines, and through initiatives like HF STATS, which we're talking about tonight. Next slide. So HFSA spends a huge efforts around workforce and professional development. We know this is an incredible topic. As we've seen, the heart failure epidemiology is only growing, and so a critical mission is to help grow the workforce. And that's not limited at all to just the physician workforce, but it takes an incredible group of expert professionals to take care of heart failure patients from advanced practice providers to PharmDs to bedside nurses and therapists, social workers, et cetera. So we really wanna be the go-to space for workforce development across all these different specialties. And I just listed a few different activities here. We do the speed mentoring and career development at the annual scientific meeting. There's actually a very nice career center for people on the website, for people looking to be matched with employment opportunities. There's been a lot of discussion around how to address the decreasing people going through the match for advanced heart failure and transplant cardiology. And we have an ongoing task force around that. A really exciting initiative that we're working on is developing a database of the heart failure clinics in the United States. This seems like something that would be already out there, but actually there's a huge gap in understanding who's out there to take care of heart failure patients. And this could be something incredibly useful for research, for people looking for job opportunities, and also for patients wondering, where can I go to get the top and best heart failure care? And then finally, fellowship of the HFSA, a key milestone on people's career development, really signifying their dedication to the field of heart failure. Next. So I talked about educating clinicians, but of course we also wanna engage and educate patients and their caregivers. And we have a number of ongoing activities. We have webinars. I noticed the most recent one was about how to navigate the holidays, which maybe we could all use some advice about navigating all the Christmas cookies successfully. But HFSA has a really great and probably underutilized educational modules. We do Heart Failure Awareness Week, and we really are looking to increasingly engage with our patients and their families and their caregivers through both education, but also through advocacy. So if you'll go to the next slide. A goal in our strategic plan for the next few years is actually to activate our patient members. We actually have, a lot of people don't realize, about a third of the members of HFSA are actually patients or patient caregivers. But I think historically we've not done as much as we could have to activate those people. We have amazing patient advocates like Cynthia Chauhan, who's joining us for the panel tonight, but we need so many more people like Cynthia to engage in their care and engage in being advocates for funding, for education, for all the things, for research, for all the things that we know are gonna be critical to closing these gaps. So be on the lookout for important work that we're gonna do to try to grow the toolbox for our patients to how to be advocates, not just for themselves, but for heart failure more broadly. So next slide. So I'll close there, but I just wanna say, there's incredible opportunities to get involved with HFSA. If you're listening to this webinar, but you're not an HFSA member, please go to hfsa.org and join us. It's the best thing you'll have done for your career in heart failure. And with that, I'll close. And thanks for the opportunity again to talk to you tonight. Thank you, Dr. Falker. We encourage all of our participants to post questions in the Q&A section in the lower portion of your panel. And as Dr. Falker stated, we welcome you to become members of the HFSA. This is an amazing community, and we want to collaboratively change these adverse trends that we are seeing in the epidemiology of heart failure. With that, I would like to now invite Eileen Hish and Cynthia Chohan, who will lead our panel discussion. They will address some of the questions that we see in the chat, as well as in the questions. And Eileen will pose some questions to our panelists. Eileen. Thank you. Thanks. What amazing talks. I think I've learned so much. I'm gonna start with the first wonderful question posed. To what do we attribute the increase in heart failure diagnosis in the younger population, 20 to 40 years of age? I can start, and then of course, I would welcome comments from our participants. I think there are several reasons why we're seeing the changes in both the incidence and the prevalence of heart failure in all populations, as well as especially in the younger populations. Number one, there is recognition of heart failure as being a cause. In the past, there was, I think, an emphasis on ischemic heart disease or coronary artery disease as being the heart disease. Now, people are recognizing there are entities such as cardiomyopathies and or heart failure even in the younger population. So one is about awareness and ability to document and capture the diagnosis. The second one is probably the clustering of comorbidities that are now starting very early on. And we're seeing in our adolescents, as well as younger populations, the cluster of obesity, metabolic disorder, high blood pressure, and others. The third reason, likely, is we are also seeing a rise in cardiotoxicity, agents that have potentially detrimental effect on the heart. And we have just recently going through a COVID scene with pandemics, as well as infectious causes have large scale of populations could be vulnerable to certain etiologies. But cardiotoxic drugs, as well as cardiotoxic entities, substances, as people's exposure is probably playing a role. And finally, environmentally, we're also seeing changes. We're hearing and or recognizing that pollution, as well as other changes that are happening in our environment may result in cardiac dysfunction as well as heart failure. So I think with all of these combined, we're able to diagnose earlier, recognize the abnormalities earlier, but at the same time, I think the risk is also starting early ages. And it is not solely ischemic heart disease that causes heart failure. There are a variety of causes, genetic cardiomyopathies, as well as a variety of other entities that is being recognized as causing heart failure. So with all of these, I think we're seeing a rise. I will welcome comments from Dr. Falkor, who has done a variety of studies and published the pivotal studies in terms of dilated cardiomyopathy outcomes and proportions in New England Journal of Medicine, which we still cite, Mike. So if you would like to add comments and then we could ask others to add on. Yeah, thanks Bikham. That was a great summary. I mean, I think as was said, it's a combination of things. I think there is greater diagnosis because of awareness and also the use of natriuretic peptide testing is a lot more common, but it's important that I don't think it's just that, because if you're just increasing diagnoses, you're actually diagnosing people earlier. And so that was the driver of more cases. What you would see is that mortality would actually seem like it was going down, which is not what we're seeing. We're seeing the opposite. So I think there is some part of it that is maybe earlier diagnosis, but clearly we're seeing a lot of trends and Bikham touched on a number of them that have changed. I mean, one thing we're really understanding now more than we did 10 years ago is I think people are very familiar with the idea that hypertension is a risk factor for heart failure, but obesity is an incredible risk factor for heart failure. And a variety of cardiovascular diseases. And so I think a lot of the epidemiologic trends that have been pointed out in the general population, especially in Western populations, are we're really seeing the sort of adverse effects of those as those problems manifest eventually as heart failure and potentially at a younger and younger age and whether those things will be changed by some of the, we obviously have a lot of exciting new developments in the treatment of obesity and some of which have relevance to heart failure as well. And so how those will play out, I think is still too early to tell, but I'm certainly interested in everyone else's thoughts. Can I pose a question to Eileen? Eileen, we're also seeing a lot of maternal mortality increases, especially in the United States and there are growing recognition of increases related to pregnancy-related complications being a risk factor for future development of heart failure as well as heart failure mortality. I know you're an expert in women and heart disease. I want to pick your brain about potentially that playing a role for younger populations as well. No, personally, I think you all have provided a very extensive answer to the question and it is not that simple. That's kind of what you pointed out, that we have a lot of changes over time and those changes include not only recognition, but also actually risk factors. And some of those risk factors are kind of just simple things but others are drugs that are being used that we think are harmless for one disease that could be causing harm for something else. And these could be illicit or non-illicit with regards to that. I have no good answer for you, Biko, for the periparty myopathy as well as just all maternal mortality. That is such a big issue that a group of us as stakeholders were asked if you could designate money for women's health, where would it go? And it was to answer that question and money was designated for that purpose. So if I answer it correctly, I would say, I still don't know. And for anybody who wants to do research, please Google. The NIH has a lot of money now set up to actually start answering these questions. This was actually a huge bucket that needs to be addressed and one of the disparities in care. I'm gonna ask a couple more. Could I ask you a question about that? Oh, yeah. Does the problem have anything to do with women waiting later to begin their pregnancies in their own ages, starting having children later in life? Yeah, that's a wonderful question and I don't know the answer. I mean, periparty is surely actually more common in the older women who get pregnant. That is a known risk factor. And as we get older, there are more comorbidities, right? We always say this is a stress test and you're probably less likely to succeed if you're stressing your heart at an older age. I really don't, I think that's probably one of the factors. I just don't know the answer beyond that. Thank you. Great question. So there was one question and Bika, I'm gonna ask if you answered this too, because I think it was before your slides giving the top 10 things we cannot forget. But prior to that, we saw so many slides about subgroups that it looked like to some that the rate of hospitalizations were declining and then mortality was going up so that you had that concern of whether or not we're causing harm when we don't admit. And that has happened over time, may still be happening, but I want you, because in your top 10, you wanted to really make sure everyone knew that actually we have a problem of a rise in both this time. But I'll let you take over. Correct. I think the question that came about whether forcing reductions in hospitalizations may result as a causality of increase in mortality is a very good question. At the individual patient level, we recognize premature discharge or incomplete treatment and or not recognizing complications do carry a risk. We at the individual patient level recognize not everybody can be discharged within two or three days. And we recognize that currently in our administrative processes, there are penalties associated with either longer length of stay and or readmission rates, and we intend to prevent preventable re-hospitalizations. We also recognize a significant proportion of the hospitalizations are not preventable. So the debate about whether, since the penalties have been implemented, whether the decline that was seen subsequent to CMS's enforcement resulted in a secular trend for increased mortality at the national level. By some studies that has been published by Drs. Fonaro and others looking at CMS databases, there had been suggestions of an association as heart failure hospitalizations declined, the mortality rates were noted to be higher. Similar rates or changes were seen from the Veterans Affairs population, but Dr. Harlan Krumholz who provided further updated information from CMS itself did show flat curves, meaning no, in essence, increase in mortality rates while seeing reduction in hospitalization. Causality has not been proven at the population level. The concern is there for inappropriate discharge or premature discharge. At the guidelines, at the US guidelines, which is ACC HFSA guidelines, we do emphasize patients to be treated appropriately and not to be discharged prematurely. And there are also expert consensus decision pathways emphasizing that discharge prematurely can result in a subsequent early readmission. So I gave a long-winded response as possible, but not proven, can happen at the individual patient. And the trends that were seen for reduction in hospitalization happened after the penalties, and thus there may be some association with that. And I think we are now advocating for performance measures to reflect validated measures that are associated with improvement in survival, such as optimization of GDMT, timely initiation of GDMT, rather than just administrative measures such as counting the readmission rates or length of stay. Would love to get comments from others. That's a long-winded response, but I'm hoping that I answered the question. Does anyone else want? I don't want to actually. I think Beacom, you hit a passionate subject for her, and I think that you're probably gonna get your best answer actually right there. Does anyone else wanna add anything from the panel? This is, I guess, mildly divergent, but one of the things as a patient I think about, and I'm a long-term survivor, I'm going into my 11th year post-diagnosis, stage three heft death, but I think engaging the patient in active understanding and intervention of their life, not just seeing them and sending them home, is something along the palliative care lines and engagement of nutritionists to help them really look at how do I live my life? How long do I wanna live? What am I willing to do? What am I willing to give up? I think these are things we also need to talk about when we talk about the role of hospitalization in the patient's lives. Physical therapy, cardiac rehab, all of those things, I think, play into how long and well we're going to live, whether or not we're hospitalized. Cynthia, that's such an important comment. I think it touches me greatly because I think that we're so used to, as caregivers, focusing on what pills we're gonna give you and what else we can do for you, and yet you reminded us so beautifully of the fact that you are a person who has to have quality of life, and that quality means that you have to be able to enjoy being with family, you have to be able to enjoy simple things like getting around your home and eating a meal. These things do matter. And I think that a lot of transplant physicians were reminded of it in a piece that was quite painful to read from a patient who said, I'm not gonna be grateful for my heart that I received because that they were angry that we had not made enough progress over time to extend their life and focus on the quality of that life because of the side effects of medication. That was, it chilled all of us. It chills me to think about it today because it is true, and that is why HFSA embraced and was one of the first to embrace bringing the patients in because we need your voice. We need you to remind us about that, and that's a very important point. I just think it's really important that we approach it as partnering in care. Yeah. We are not done on two, but done with, and that we have an important voice. And I really think, a lot of us carry a lot of comorbidities. And so the balancing act is incredible. And for us to be working together and pulling in all the resources and supportive interaction, I guess, is what I think is often missing and is really important. Yeah, there's no question. I think you're absolutely right. And often y'all have better answers than ours. I think that that's very true. I'm going to ask the next question, which I have a feeling we're going to get a lot of different answers. I may even begin the discussion, which my answer may be the more controversial one, but it is about when to stop the guideline medical therapy. This person is working in a SNF, and they worry when the blood pressure is less than 100, even if a patient has no dizziness, no symptoms, or if their MAP is less than 65 or 60, they do actually stop the medications. And their comment is, should we, what should we do? And I know we're going to get lots of answers. And I'm going to start the most controversial part. I'm going to say that the teaching and dogmatic guidelines, not guidelines, it's actually never been guideline driven. Never, but the teaching, no matter where you have trained across the entire US, I don't know if it's in the European training, is that do not stop at all. That is, wait for your patients to be symptomatic. And the reason behind that is that they say, you know, Starling's Curve, that the lower the blood pressure, the less resistance for the heart and the easier it'll be. So what's my controversial comment? Go ahead. When I went, I don't do that at all. I don't do that at all. and the reason is that when I arrived well first of all I think we all went to school and they told us that 50% of whatever you learn is gonna be wrong okay and at my school they were very kind and said you know you could be the next person to come up with the right answer if you pay attention so I started my job I'd like to say it was a few years ago but it was many and I had an office next to to to the ICU and every time there was a code or anything I would go into the rooms and I noticed that even without a code all these patients and that were heart failure in the ICU had multi organ failure not just heart failure but at the moment they had multi organ failure and as I went through the records the one thing they had in common was that their blood pressure when they came in was very low and there is a point where you hypoperfuse meaning that you don't give enough blood to the organs and so when we this is my viewpoint but that threshold is probably like a systolic like a little bit probably closer to 70 just to be honest with you but the problem with giving people medicine at 90 or 80 is is because you don't know when they're gonna get dehydrated one day you don't know what else is gonna go and you can't control that next step and they will take their pills all of them and I don't want them to have multi organ failure to have to do that full rescue so my goal is to keep their blood pressure at a hundred they have enough wiggle room around time so I to reduce the guidelines say it's okay to kind of make your own choice it doesn't provide you that answer so but my controversial answer to that is that I do not hypo I'm fearful of hyperperfusion I know for a fact that it doesn't happen at systolic of 90 or 80 but it gets close and it gets dicey and so I don't like to play with that I kind of I usually after reducing though look for the cause if it is a sudden decrease it's almost always dehydration so although I may hold the mess the next thing I do is kind of assess why it happened if it wasn't there before so I'm gonna jump in and I am gonna emphasize that in the question I think the individual pose that there were no symptoms in the setting of asymptomatic number I don't withhold or reduce and I do actually I have a variety of patients who live with the systolic of 90s even 85s and or even 80s and I think the concept of that you're underlining is recognition of shock versus a number and I think hyperperfusion state called the clammy extremities hyperperfusion is an entity that people need to recognize but at the same time that's not solely a blood pressure recognition it's a syndrome that is totally different with a with unique features now for the remainder of the population I want to emphasize three things number one the lower the blood pressure is the sicker the patient is therefore that this will represent a group a group of individuals who are actually with a high mortality and in all of the studies clinical trials with guideline directed medical therapies regardless of the subgroups of blood pressure ranges that they were used be it 100 to 110 or 110 to 130 and or above now especially with the new agents there appears to be similar benefit regardless of where the baseline blood pressure is mind you in most studies blood pressures less than 90s were usually excluded but having said that these individuals let's say I have an NYHA class 3 blood pressure of 90 individual the sick individual who will likely die if we don't use a GDMT I make every effort to not only initiate by optimized the second thing that I do is as you said with the optimization of GDMT the diuretic use need is less I actually reduce the diuretic dose if they don't have congestion and or not needing it anymore and the third thing I do I look at non cardiac meds and I know Robert probably will hone this home and I look at of course the BPH medications the alpha blockers the other vasodilators and I either stop those if they're not in needed and or spread the meds apart and with an agents and I'll ask Robert to comment on this there are some nuances of how to change to agents that may not drop the blood pressure too much Robert thank you so much dr. Buskirk and and again when I'm asked this question by my medical residents and internists there are a few things I always ask number one is what is the trajectory of that patient honestly you know low doses of all of these meds you have of what over 70% reduction in overall death but what you need to ask yourself the question through shared decision-making in number two is with regards to again what what your patient wants what are their expectations and also communicating that and then finally number three you have to take into account if mortality is what you're looking for I mean it seems like almost every drug reduces hospitalization nowadays but in terms of mortality you got to look at what meds are actually if by increasing the dose you have to you're going to be sacrificing renal function blood pressure whatever versus that benefit of death as I mentioned before beta blockers definitely have that benefit when titrating up that dose the other issue that comes up are unfortunately believe it or not I I see almost and dr. McElvin and can comment on this I see almost every one of our heart failure patients that are being evaluated for for transplant and some of the basics like one oh like heart failure 101 insets what what I can't someone in the patients will say you never told no one's ever told me that and I know that's come up on rounds multiple times but I that's one the other are these nutritional supplements that have multiple ingredients like means that you don't know but I do know so I can look at that and go oh my god that's a hundred percent caffeine that's really what that is and so evaluating from that standpoint as well but the one thing I recommend before deep prescribing is communication because there may be someone on the other end where they came up with some of those regimens that that was something that was thoughtful and so I always recommend anytime you're gonna have you need to touch base with with the overall cardiologist of primary care provider and then finally now that we have access to the web with all of these or I mean even things like cannabis and you'll be anyway I and again that's the research that Colleen and I are doing now again one in three patients using cannabis within our institution who have heart failure so again that plays well there's so many other complex things to consider but again the approach that I try to communicate and I thank y'all for also clarifying because there is a distinction between somebody who actually is end stage for which that is their normal blood pressure versus somebody who actually kind of has more of an acute change because something is is wrong and so you know it especially in the sniff I think that that that patient had a different blood pressure probably in the hospital maybe or not and I think it matters I also just want to add that someone from the UK said that the dogma teaching is the same in the UK as it is in the US I have to end the last question was something that is kind of dear to my heart and I'm curious what everyone's gonna respond but you look at this all those slides with mortality and as you shaped and and it turns around 2012 2013 and it and it starts to go upwards and you know I think to myself what the heck is going on we as we you know have discussed that all the advances in care occurred you know after that we have more meds we have actually you know a lot of different ways to even temporarily help people survive in the hospital with newer you know smaller machines machine cards and even the L VADs that are durable now are smaller that fit in women as well as the man and have been perfected to the point that they actually have better survival and you know things are looking up okay so what's going on and what goes in my head I'm kind of love to just kick off the discussion is a lot of the things that have been kind of mentioned you know the risk factors have changed so that we have more obesity we may have actually more hypertension we have more risk factors but I also want to point out that there were diseases we didn't even recognize we didn't recognize amyloid and I bring that up because thank goodness we have recognition and we have drugs but now we have a population of people that we may have said they died from something else we didn't really understand it and I kind of wonder if that adds a role the other is that you know we have a lot new agents for cancer and we have wonderful guidelines now to actually check these patients and check their heart function whereas before they weren't getting routine echoes and so I wonder how much they may have died and it may have been attributed not to heart failure because they weren't being managed I'm curious what your thoughts are because to say it's not that they're not taking enough guideline sgl t2 inhibitors as well as actually Arnie did not exist in those years on the other side of the you for which we only really had ace ARBs beta blockers and aldosterone antagonists so with that I'll kind of end and curious what you think is the cause I'll start and welcome other comments several things come to mind number one the administrative coding has changed the ICD 9 to 10 transition and implementation of that which started recognition or specification for heart failure with reduced EF and preserved EF going into the practice and also at rebution to heart failure as a cause of death in the CDC wonder databases that I presented in the slides the concept of attribution to heart failure I think started changing around those years though still is not reflective of the true percentage so there is been a I think big unrecognition of death due to heart failure we in the clinical trials know the contribution of heart failure to cardiovascular death as a significant proportion whereas in death certificates it usually will be termed as ischemic heart disease heart disease or heart disease related death and then heart failure was not being recognized as a cause of death in in death certificates in the United States until that practice started changing around that time frame so administrative coding documentation death certificates attribution to heart failure started changing around that time frame but also we also as was recognized in the comments have issues with access to care more than ever I think the health care burden is currently increasing and access to health care unfortunately has huge disparities and and there are a large number of populations of patients like the zip codes rural health and or race ethnic and or income disparities currently are creating a lack of access to care and lack of coverage coverage has become more challenging for not only the newer agents but even for the older agents when compared to other countries u.s. is performance right now is lagging behind in that you know study that we cited evolution heart failure u.s. compared to Sweden and Japan really have very low uptake not only for SGLT2 inhibition or ARNI but also for ACE inhibitors and ARBs which are generic so in essence there is appearing to be a bottleneck lack of access lack of coverage and sicker patients especially in rural areas and or with a variety of social determinants of health not being able to achieve prompt care and again the clustering of comorbidities are also playing a role which is more than ever now we see the burden of diabetes and obesity playing a role which started I think taking a toll on cardiovascular outcomes. Dr. Bozkurt so eloquently described that and I'm going to pivot your question to end with how can we help in this space and I think I'm going to reinforce what Dr. Page and Cynthia had to say to around patient engagement and listening to our patients so for example the uptake of GDMT in the US is there's a gap there and it's lower than than where it should be but how can we educate our patients in a way that they feel engaged that they understand that they feel they have the information to take their to their clinician in order to have those conversations and I think us as a medical community need to continue to focus on how to better prepare our patients for those conversations and continue to ask them what it is that's important to them what they value in addition to arming them with the information around things like GDMT and their target doses and what medications they should be on. I'm going to ask Cynthia to provide us the final remarks to respond to that question so we can learn from her. I agree with what Colleen was saying and as she was talking I was thinking about wouldn't it be wonderful to just have in the waiting rooms list of questions you have a right to ask your doctor and to to have patients learn that they are partners in their care and to have doctors learn that patients are partners in their care that it is a two-way street that brings health. I worry about the patients in rural settings I worry about the underserved patients the uninsured patients. Patients just don't have access to care and those of us that do we tend to do better and I also I really want to stress the importance of it not being aware of the comorbidities when you're making recommendations to your patients or when patients are complaining to you about something. If their blood pressure is low have Robert or someone like him check all their meds. How are they interacting? What's going on? So I guess interactive discussion and focus on well-being. I like being alive oh and I can't leave without saying clinical trials. We must get patients into clinical trials and it can't be only at the major medical centers. We have to figure out a way to get those trials out into the communities and out into the rural areas and to help underserved populations who've been miss served in clinical trials learn that they can be well served in clinical trials that's kind of. So well said Ms. Chauhan and with that I would like to thank our panelists our presenters and the HFSA for making this available and I'm going to now pass it on to Dr. Page who will close our session. Awesome thank you so much Dr. Bozkurt. Again I want to thank everyone who just kind of echo Dr. Bozkurt on this who who've attended this seminar. I hope you're able to to go in some information apply it to your clinical practice. The last thing that I want to highlight again as you've heard from past president Bozkurt and current president Fokker. I have to say if you're not a member of HFSA and you care for these for our for our patient population I highly recommend to get involved and join the organization. It's the most rewarding organization I have joined professionally and personally the most rewarding of all of them and so highly recommend that. Number two if you're a member of HFSA these data are available to you and I want to highlight that that if these are available on the website and I've already started to use these data in presentations so I highly recommend that you go there. And then finally I want to thank our panelists Dr. Bozkurt for spearheading this whole the whole shebang and again hopefully these our hope is is that every year you will be able to have access to these data and updating as I serve on the committee coming up and there's some interesting things we're going to be looking at I'm really excited. So with that I want to wish everybody a very happy holiday and a great evening. Thanks again to the HFSA for putting on this wonderful symposium. Thank you for inviting us. Thank you. Thanks for coming everyone.

heart failure

HF STATS

incidence

prevalence

mortality rates

demographics

obesity

hypertension

racial disparities

hospitalization trends

guideline-directed medical therapy

collaborative care

quality of life