2020 Virtual Cardiovascular Evening Symposium: Vascular Surgery & Heart Failure Updates
Originally Broadcast: Tuesday, November 10, 6-7 PM CST
We invite you to join your fellow clinicians to learn about cutting-edge best practices in cardiovascular care. Minneapolis Heart Institute® providers discussed topics in prevention, diagnosis, managements, and treatment of cardiovascular conditions.
okay. Tokyo being president of M. H. I is a true blessing. E get to help create a new environment for people to be helped by our teams. For those people that come to us when they need us on to create that environment, that's gonna bring them the care that they deserve Most of the time in previous institutions, I look in the operating room and I get a sense of what my day is gonna look like. And when I have to pay more attention to based on the people who are there here, the quality of the individuals and the team members from all walks of specialties and subspecialties is so high it doesn't even cross my mind. I walk in there, I know I'm gonna have a good day. But Minneapolis Heart Institute, as part of a line of health, is a national leader in leveraging something called an enterprise data warehouse. It's information from over 75 sources are cost data are Elektronik. Medical record data are patient satisfaction data nationally benchmarked registry data all linked together into our data warehouse that allows us to analyze real time costs, quality and outcomes, and to make changes in our care so that we can improve the cardiovascular care for patients throughout our population. Outreach that MH I provides provides an opportunity toe interact with the community beyond just the Twin Cities area, and that really provides a nice snapshot of the entire population we serve. MH I serves patients from five plus states in our region, and the opportunity to provide that outreach helps us make sure that we're really in the homes in the neighborhoods where those patients live with the capabilities, especially of telehealth and being able to remotely see patients. We still need someone there who's kind of the steward of that. Patients. Overall care and communication with them is very important in order. Thio give our patients the best care, especially post operatively when they're sent home. We want to be sure that have good communication and good care from primary care perspective. Aziz. I've been around the country and seeing other groups. I almost didn't even understand how unique we are and that with our own research foundation, we can. We can not only see the patient on delivering the best quality care we know of right now, but if they come with something or not as familiar with that. We say we need to understand this better. We actually have the research foundation. We bring the questions from the clinic to the research realm and then back to the clinic and even provide better care for patients. That way, it's hard for me to contain my excitement about the next opportunities for the Minneapolis Heart Institute Foundation way. Begin the next chapter of our 10 year heart of new own project by studying the prevalence of heart valve disease in an entire community, and we continue to advance our existing scientific centers for the study of heart valve disease and for complex coronary artery disease. We now have tests for cardiovascular disease that we didn't have when I was in training. And for the primary caregiver. Those things are all new and to decide which test to use in which condition, Um, you could go on our app to figure out what's the best test for that patient, and then you can hit a button and be connected directly with our scheduling department and get that test scheduled. It's using the power of the Internet, provide medical care throughout the state e Think the future of cardiology and cardiovascular care is moving to the idea of value based care, focusing on obtaining the best outcomes at the lowest cost for our patients. And that requires an understanding of how are we providing care now, where their opportunities to do better? How are there opportunities to provide that care more efficiently? That's beneficial for the patients. They achieve the best outcomes. It's beneficial for the system that it's less cost and our patients are happier because it's provided in a more efficient manner. The future of MH I is incredibly bright. We all know that health care is moving very quickly. Way have to keep up with all the technology and the latest and greatest science to deliver to our patients. At the same time, we want to keep that caring touch and be the patient's advocate, a person that they want to come to because they feel safe and cared for. Good evening and welcome to the Minneapolis Heart Institutes Virtual Cardiovascular Symposium. I'm David Hurley, cardiologists here with Minneapolis Heart Institute, and I'll be your host this evening, I said, I'm David Girl, one of the cardiologists here with the Minneapolis Heart Institute, and I'm serving as your host this evening. I also chair the Education Department for the Minneapolis Heart Institute Foundation. As you saw mentioned in our video this evening, we have a great program for you, with Dr Titus and Dr Ekman speaking. But before I introduce them, I'd like to give you a little background about the Heart Institute. On the left hand side, you'll see a list of the many programs that are offered here at the Minneapolis Heart Institute. And on the right hand side, it gives you some of the numbers associate with these many programs where we have over 1000 employees 78 positions, 52 advanced practice providers doing a wide variety of really all the modalities of cardiovascular care. The Heart Institute was really founded on the concept of outreach. Uh, it's our our idea to bring care locally, and because of this, we got over 35 sites throughout Minnesota and actually in Wisconsin to deliver the care locally and bring patients to the Heart Institute at Abbott Northwestern Hospital. When they really need advanced therapies. Not only have we deliver this throughout the state, but also We now have several locations throughout the metropolitan area. T to deliver that care even within their neighborhood. One of the popular programs we have within the heart Institute of Cardiology, Curbside cardiology curbside is really founded. The idea that throughout a physician's day they may have questions that come up in the outpatient setting or the inpatient setting where they want to know more. About what test should I order next? Or can you help me interpret this E. K G? Or perhaps they think a patient may or may not need to be transferred to the Heart Institute? Uh, curbside is available by phone, where cardiologists is rapidly available to provide just that type of insight. We also have a mobile app, um, where we can provide all of our different algorithms whether or not they be non emergent algorithms for choosing the next task. Or what an equivalent to utilize or, on the other hand, perhaps see the emergencies, whether it be a level one myocardial infarct, a Nakoula patient of shock patient and abdominal aortic aneurysm. All of our protocols are readily available on this out and on the top of the app. If you want to transfer your patient, you can quickly push the green button and be connected to our transfer center or on the bottom. If you just wanna call cardiology curbs out of the question after reviewing an algorithm, that, too is readily available. We want to promote our allegiance this year with broadcast mag. In working with Broadcast Man, they have allowed us to bring our programming such as these. Virtual conference is a directly to you and greater than the five state area. It's really done a terrific job of increasing our reach. And I also encourage you to look at our website where you can view many of the videos that have been presented over the past year. Um, that I think are extremely helpful on a wide variety of cardiovascular happened. I also wanted to bring attention to our new podcast. Cardiovascular conversations with Minneapolis Heart Institute will begin after the first of the year, and here's just a variety of the topics that are all set and ready to go. I think you'll find these very informative, enjoyable Aziz, you do your daily commute a nup coming. Uh, symposium is going to be on Tuesday, December 15, host is similar to this with Dr Newell being are cardiologists host. And then we'll enjoy conversations on preventive cardiology by Dr Twee and on surgical therapies for heart disease. Productive. Bobby Stefan, I encourage you to register for these programs now, our seekers tonight you can see their objectives in front of you. First, Doctor Titus hails from North Dakota, where she went to the University of North Dakota for medical school. And from there she went on to the Cleveland Clinic to do her general surgery, residency and vascular surgery. Dr. Titus is an expert in really all forms of vascular and, uh, vascular and endovascular surgery on, and, uh, she also works on both Venus and Arterial disease. Our second speakers are to Peter Eckman. Dr. Eggman started his educational career because Davis Adolphus and went on to the University of Minnesota and the Cleveland Clinic to do internal medicine, cardiology and advanced heart failure. Peter actually leads are advanced heart failure and transplant program and speaks nationally on heart pump mechanisms on and has published widely in this particular area. We'd like to thank a line of help learning and development team for allowing us to provide CMI credits for the program this evening. Uh, and here are disclosures. Hi, everyone. Thank you for joining tonight. I'm Jessica Titus. I am one of the vascular and endovascular surgeons with MH I at Abbott Northwestern Hospital. I'd like to thank you for joining here tonight. Um, I can I have no relevant disclosures other than as Dr Harold mentioned. I am a native North Dakota. And after my brother in law sent me this home Covad test option, I now understand why things are getting quite bad there. Uh, but in all Seriousness Cove, it has changed the way we do medicine, at least in the short term. And so I tried to highlight in my talk here tonight some of the concerns with vascular surgery in particular and how to manage certain vascular situations. Uh, during this crisis, common vascular pathologies that we treat these air kind of our big four here. Aneurysms prefer arterial disease crowded and venus disease. Uh, and certainly we see a fair amount of all of these. I decided Thio concentrate on peripheral arterial disease and crowded disease here tonight, but I'm glad Dr Harold mentioned the podcast as my topic there was aortic aneurysms and specifically deceptions and emergencies. And so we certainly still offer the gamut of all of the endovascular, these air all graphs that are currently in active use or our trials in which Abbott is involved in, uh, in addition to that, we haven't forgot how to do open surgery And, uh, on the aorta and its major branches, these air, all just pictures from cases. So much so, in fact, that we like it were even willing to work with the cardiac surgeons. Uh, so tonight the outline is we'll talk about the diagnosis and kind of highlight urgent versus elective situations when it comes to these two pathologies screening who should be screened when they should be screened, who should be sent to vascular and how we decide whether to operate on them or not. And then we'll look at current treatment options for both of these crowded artery disease. Uh, first of all, I think we all know stroke is, ah, serious pathology. It is the leading cause of death globally, and number three here in the U. S. Not only that, but it accounts for 214 billion per year in health care spending in the US alone. Most of these strokes are ischemic, with about 1/5 of these due to carry out a disease. The other pathologies are cardio, anabolic and small vessel disease within the brain. There's a recent study that came out in May of this year in Lancet global health that actually looked at created disease prevalence in the general population and found that 21% of people aged 30 to 79 had evidence of crowded plaque. Now 1.5% of the general population has actual significant created stenosis being defined us 50% or greater. Instead, again, a typical that sweet. And there is a significant variability by region, with Africa having the lowest rate and the America is being somewhere in the upper middle. Eso urgent or emergent concerns for created disease is going to be anybody with symptoms. And so we know the highest risk for a further neurologic event is going to be in the first two weeks, following either a. T. I A. Or a small stroke. And so in patients you're seeing with Amoros iss, um, or a recent t A, they should have an expedited work up. And certainly, if they're having an acute stroke, they need to be seen in an urgent manner. In In that situation, they'll get to meet one of these lovely three people, which is a stroke neurologist at Abbot, that we work quite heavily with. That's Dr Mark Young Pad, Rouhani and Ron Terrel pictured there, uh, also in the situation of a coup created occlusion. There's new research that's kind of recently changed, saying that there is, uh, utility toe opening up acute occlusion, salvaging the N, C A A and a CIA if they're able and then along with our narrow intervention list, pictured here, uh, they'll go get the cloud out of the M C a c a gently balloon, the common created or internal carotid where the disease lies, and then we do a staged endarterectomy. Our results with this have been actually quite good. We delay the crowded endarterectomy until we see how the neuro salvage will go, and that's where again the stroke neurologists come in heavily and helping guide us on when on what to dio screening. So those who aren't asymptomatic when we look at screening guidelines, we're mostly looking at three big entities within vascular surgery. And that's gonna be the U. S. Preventive Task Force, our governing body, which is a society of vascular surgery, and then the American Heart or American College of Cardiology. And so we'll go through these with both created and peripheral disease. And so the U. S Preventive Task Force is not recommend screening in the general population with a great deal recommendation. However, that's currently being updated, and I think, based on what came out in The Lancet, and I think when they come out, they'll look more similar to the SBS and H A guidelines. SBS recommends asymptomatic with multiple risk factors who are still candidates for an invention, and these are gonna be people with clinically significant peripheral disease. As we'll see, peripheral disease is really a marker for underlying other pathologies, and that's what you have to keep in mind when managing these patients. Otherwise, if they're greater than 65 they have coronary disease, smoking hypercholesterolemia or if they're in pre up for cabbage, mostly related to trying to prevent inter operative strokes, A, J and A C C are similar, but actually extended to even all asymptomatic patients with a brew we or other cardiovascular risk factors such as a Triple A or coronary disease. Screening involves a crowded duplex, which is a relatively quick study, not overly expensive, and you'll get the results you see here. Uh, this is the color Doppler highlighted here with pretty high velocities 3 13/50. And then this is the gray scale of it, and you see a significant amount of of calcification with pretty severe signal drop out there. And so this person probably has very underlying severe disease and should be seen. Once the results are completed, you're gonna see the report in three big categories less than 50% 50 to 69 or greater than 70. And that's based on the Doppler speeds, along with the ratio. Comparing the internal to the common karate vascular surgery referral should be considered for patients with 50 to 69% announces indefinitely for those over 70%. If you are going to follow them on your own and on and don't think they need thio, come to a vascular surgeon, yet follow up ultrasounds if they're less than 50% in their greater than 65 years of age unless they have a significant risk factors. You probably don't need to look again if they do have significant risk factors in general. And repeat ultrasound in 3 to 5 years is reasonable for those who are 50 to 69% on the upper end of that range, we usually stay green on and follow them every six months. Treatment options uh, first and foremost, front line therapy, regardless of what you decided to do, is going to be medical. For patients who are extremely high risk for operation. This may be their only modality of treatment, including aspirin and a Staten dual anti platelet for symptomatic patients that are inoperative candidates or have small vessel disease in the brain. That's significant. I and then risk aggressive risk factor modification. Uh, once you're looking at intervention, your options are endarterectomy versus stenting. Seen in the pictures here, the comparison within stenting. Uh, there is the historic transfer Meral on. Then the newer kid on the block is the T car on. And the rationale for the development of T car is in all the trials that had major trials that have been done prior. Comparing endarterectomy to stenting. The Strokers was higher and stenting, although the M I risk was higher in the end art and so for stroke intervention in general, uh, scenting never gained widespread favor. But when you look at the distribution of strokes in that population, they found that actually a fair amount of those we're in the Contra lateral hemisphere. And so a lot of them were due to either a diseased aortic arch or the significant tortuous OSCE ity and the torque on the catheters. Once you get all the way from the groin up through the internal carotid, especially in a tight stenosis along with this, we inherently feel that distilling bolic protection helps prevent neurologic events. However, from the groin, um, your only two options air really crossing the lesion in order to put in a filter and risk knocking off something at that point. Or quite difficulty balloon flow reversal systems from the groin that never really were large enough more toe gain any significantly robust flow reversal. And so out of this was born T car and you can see the video here on what it involves is a small incision above the clavicle on Get down to the common created itself actually get around and get control of the vessel. They're put in a purse string, as you see here, for the placement of the sheath sheath goes directly in under surgical visualization into the artery itself. And then we actually access the vein in the groin, using the pressure differential to actually reverse flow within the crowded. That way, when you're putting it in your center balloon, you can see the debris that breaks off actually get sucked back through. The sheath, which is actually eight French on DSO, creates a significantly robust flow reversal. The debris is captured in a filter before it dumps back in the vein. Once the stenting is completed, the artery is primarily closed and the skin of the small incision is closed. This could be done awake, um, and or under general anesthesia and requires an overnight say, much like transfer, moral standing or endarterectomy. Abbott was involved in the major trial that recently was released in stroke in September. It was the Roadster to which basically looked at widespread use of the T car procedure in the general population of vascular surgeons to see if the outcomes from Roadster. One would hold up because Abbott was one of the top 15 and rollers. We also made three author list, which was nice. Um, findings was a composite 30 day stroke and death risk of 300.8%. And when you included M. I and there was 1.7% thes results are similar, if not slightly better than historic studies for endarterectomy itself and certainly better than the transfer Meral stenting. And so I think this is going to become more widespread. But I think it's also important. Thio make sure that they're seeing someone who can offer all three approaches because, uh, choosing the right approach for the right patient, they all have different advantages and disadvantages. I don't think open surgery will ever go away because of cases like this. This is a patient who is referred to me. He underwent an endarterectomy, Riess denounced that, underwent a stent, then got another stent for restenosis of that and came to me with a 95% symptomatic stenosis. We went and we endarterectomy eyes this segment and this is layers upon layers of disease with soft, gooey stuff in the middle. That was very concerning Hey, underwent a open in her position, grafted the crowded with Stephanie Spain and did quite well from that moving on to prefer arterial disease. Uh, effects 8 to 12 million Americans. It's actually a quite common disease. Um, but when you look at the natural history of cloud occasion so just leg cramping on I think this is something important for patients to know. Because once they hear the diagnosis of peripheral arterial disease, I think their concerns jump directly to Am I gonna lose my foot? You know, uh, and amputation and all the fears that go with that communication is a pretty benign pathology overall on its own. And so five year outcomes with specific regard toe limb, limb salvage and limb outcomes show that 70 to 80% of people at that five year mark will have stable cloud occasion symptoms. So one block, two blocks, whatever they start with worsening cloud occasion will be seen in about a third of these people on Lee, 123% advance to critical limb ischemia. But as I highlighted earlier, one of the bigger concerns with peripheral arterial disease is it is a really significant marker of underlying cardiovascular systemic disease in general. And when you, um um gentleman party vascular perspective, all these clock, it's 20% at five years will have an M i. R. A stroke in 10 to 15% will be done. When you look at moving onto critical limb ischemia, the prognosis gets much more profound. At one year, about a quarter of these will be dead from various causes, mostly cardiac related, and 30% will have undergone amputations. So when you look at this at one year with the diagnosis of critical limb ischemia, Onley about 45% will be alive with both legs at five years. That gets even more grim with 60% mortality. So it's a reasonable thing to look forward to find. Um, however, screening recommendations haven't really caught up with this yet. The U. S Preventive Task force doesn't offer much guidance at all, saying it's just I S P s and H A A. C c pretty much agree that typical symptoms and exam findings. It's reasonable to get an A B I, uh, or even if you have multiple risk factors without symptoms. But since it is such a significant risk. Stratification. Marker for C v mortality and morbidity In general, it's reasonable. Thio, get a baseline and see where you're at. Symptoms are going to range from acute sensory and motor dysfunction. Thio Claude Occasion. Just simple calf cramping at a certain distance of walking and then critical limb ischemia, which involves rest, pain or tissue. Us rest Pain is sometimes a tough diagnosis to make, because leg pain at night can be so difficult. Or really, it's when the leg is elevated and so fighting against gravity along with falling asleep when the heart rate and the blood pressure lower associated with this, they don't have enough flow to even perf use and keep their muscles alive at rest. And that is a significant marker for for the risk of limb loss. So screening is gonna be with a B s. You can see even quicker and, uh, more cost efficient than the carotid duplex. And it involves just blood pressure checked at the post, your tibial location and the dorsal SP dislocation, and then comparing that with the arm. Uh, they results are expressed in a ratio, with normal being 1.9 to 1.2 you also want to look at the wave forms. If you have mono physic wave form with a normal A B I, there may be a chance that they're superficially elevated and that it really just have heavily calcified non compressible vessels, in which case we would generally get a T B I. Also, if you see a B I is in the range of 1.61 point eight. This is likely what's going on. Mildly reduced categories 0.72 point nine and then moderately reduces 90.42 point seven Severely reduced. Getting into the critical limb ischemia phases less than 70.4. You should consider vascular surgery referral uh, in urgent manner for anybody with an acute component to their system. Their symptoms, especially if that involves motor or sensory dysfunction. Because that is a sign that there is something acute going on in limb salvage, uh, chances reduced as time goes forward. For us, moderately reduced. FBI's would be reasonable for us to see them certainly if they have lifestyle limiting symptoms where they can't do their daily activities on wounds. And so having a vascular surgeon take a look at these um, whereas this wound would be concerning, I think to a lot of people, I'm much less worried about that. Then I am about the feet pictured below, and that's because this gangrene is dry. It's not infected looking. This took a long time to get there on DSO. The underlying diseases is probably mostly chronic on DSO. We do have some time to deal with this, whereas this guy with a normal looking foot on the left and the pale, bloodless foot on the right has something acute going on in needs. Emergent care treatment again is going to be medical management with risk factor modification Staten and an aspirin walking program involves basically teaching them to walk through the pain and do that on a regimented basis multiple times per day. With this people, I tell them they can walk themselves out of symptoms at times without needing a procedure at all. There's also ancillary medications, including please tell Plavix and Xarelto. Little is a medication that works well for those who are able to tolerate it, but it has a pretty hefty side effect profile. And so I'd say probably only about 40 50% of my patients are able to actually tolerate that medication. Xarelto is relatively recently proven to be helpful at lower doses per peripheral arterial disease. Inter vision thresholds, certainly for any acute symptoms will be urgently or emergent li intervening wounds or ah, lifestyle limiting symptoms depending on their results with a walking program and conservative management. When looking at treatment, Endo versus Open open is going to be your typical endarterectomy is or bypass. Endovascular is really advanced in the recent years, and we're going to go through some case scenarios here in different options for treatment of this. But really, a lot of the advancement is gonna be in using these together. And we'll see some case scenarios, including that, um, using both the endarterectomy and stenting. We're a jumped of procedures such as thrown back to me devices. Uh, also when considering access options, pedal Axis has also really become a routine part of our care vessel prep. I'm going to go through these first two a little bit more in depth and show some case scenarios. Um, chronic total inclusions such as crossers to kind of drill through that top calcium cap can be helpful or if you're in a seven to mull plane. There's also now reentry devices. The Outback is pictured here, which actually puts a little needle back into the true loom and when you're stuck in the sub in tumult plane there to get you back in so you could do your intervention. Also, thrombosis removal devices, including far Michelman can ical or solely mechanical from back to me. And then there's also just simple suction from back to me can be useful in certain situations with all those options. Obviously, we don't have time to go through all of them, but I think I'll highlight the vessel prep options here. And so, uh, looking at these, it's going to be a threat to me Or Shockwave are going to be your main to with shock waves being newer to the peripheral vascular disease armamentarium. The calcium in a blood vessel could really inhibit your ability to treat, because if you're stand, can expand it either. End up Mala posed, as you see with e center calcium here in the blood vessel or under expansion Andi, significantly narrowing an already narrowed artery. And so getting those stents open, getting their balloons toe open, the vessel with that rigid calcium has been the Achilles heel of endovascular intervention. And so after rectum E is born out of this options, there are four different types of after ectomy at this point that are approved for the peripheral. Ah, disease. Directional is the first one on, uh, this is involves a catheter that basically has inner blades or cutters. And it's called directional because you can change where you want that blade to cut. And so each centric calcium it can be useful for that s f a origin or pop little disease. It works very well. One thing you want to consider. With this eyes, you have to use a distal filter. It seemed below because these air the pieces of things, you pull out of there and obviously you don't want that to sail into your pedal vessels. Uh, next option would be orbital or 3 60 on this is a quoted crown that has, ah, abrasive materials such as diamond particles, and it just spins as you can see or imagine from the picture. This is really good for a circumferential calcium. And then we have two options for for softer plaques, their intent, instant stenosis, there's rotational, which is basically this rotating high speed cutting blade or birth on. And then there's also the laser, which actually use this photo ablation to vaporize these plaques into CO two and water. Uh, Shockwave, like I said, is the newer kid to the game, and it's well known use in the treatment of kidney stones on calcium. There, this is basically a balloon that goes up and an electrical discharge sends shock. Uh, our pressure wave sonic waves through this balloon to kind of expand and and deflate it, creating a pulse that goes to the calcium and creates these micro fissures that softens the calcium and then theoretically, will expand better with your lunar stent. This is a recent case of mind. This is an S F A lesion. You can see here with serial blockages in some feeling of the intervening segment, but you notice the heavy chunks of calcium kind of all along the path I was able to get through in the true looming with a wire and did not go. So been to Mullen. So we treated with Shockwave and you can see here from distal to proximal uh, there's a significant distortion of the balloon at a couple locations in this middle one is a good example of what you see with the shockwave balloon Over time, Uh, you start with very low atmospheres and just let it shock and eventually the balloon opens up. It looks like that, Andi, that's when you know you have a good vessel prep for later placement of ah stent. Or I started with drug coated balloon angioplasty in this situation and, uh, ended up in for Europe, let alone for the self expanding stent. And you could see there's still a little bit of a turn there by that a center calcium. But actually that's a women expanded to six millimeters on its own, and the flow through was quite robust. So that is the remember the first picture that is our final result there. And then also they had to a short segment popular till blockages that was a limiting flow. So we hit that with the drug eluting balloon, and the final result was actually quite good. Um, another case example of hybrid access and thrown back to me for this one. This is the sixties a woman in her sixties who presented with acute motor dysfunction of actually both legs. She had no known prior peripheral vascular disease. But on questioning of her history, she clearly had some some clarification for years that was advancing. So we thought likely acute on chronic Took her for an angiogram, an intervention as on c t. A. She had some acute thrombosis looking stuff in our in our distill aorta along with heavy disease. And so we got up from actually both groins shot in angio here, and you can see Thean Farina Lior toe clues right at thes Lum bars, uh, ballooned our little path with a small four millimeter balloon just to get a new idea of the underlying flow. We were cut down on both groins because we did this in conjunction with Tamerlan are direct Amis. And then we're able to actually clamp the s if they and any thrombosis that we just lodge were able to flush out of the artery before we close. Um, because of that, we put in a teepee a with the angio jet and let it sit for half a now er and then did pulse spray and aspirated it out. And this is our final result. With that, you could see it uncovered a pretty significant underlying aortic stenosis along with bilateral common and external. He treated this with an arid extent and bilaterally extents, and the result was quite good. She actually left the hospital the next day with palpable pulses and full motor and sensory function. People access case 84 year old male with a severe coronary disease that was non drove. Ask your eyes have also not a great candidate for any consideration of open operation who had severe ischemic recipe in and a new great toe wound with infection. It actually seen one of my former fellows at another institution on duh. Couldn't find a really suitable target for a bypass even if he wanted. PT was open at the ankle and unable to cross the distal s if a lesion. So we took him for an angiogram and a repeat attempt with planned pedal access. You can see here there's a little a V official A that he left me, which of course, I gave him a little bit of heck about, But the distillers are the disapproval of deal or pop. A little includes right here at the knee joint and you could see distantly the post your tibial comes back. I shot a lower picture with higher volume contrast. And actually, you can see a para Neil come back as well. Um And so because of this, I felt comfortable sticking the post. Your tibial, that's the access right above the ankle came up, was actually able to get through an integrate into the Para Neil and retrograde through the poster. Tibial was in a bit of a different plane with these two here. And so I actually ballooned from above, pulled my wire back and was able to get back into the same plane. Did Buddy ballooning of both of these and you could see the result was actually quite good. He was able to heal his wound, putting all of our access options together. This is a recent case of my partners, Onda. I think it really highlights the different thought processes and use of different equipment at our disposal. And so she saw a male in his seventies with a non healing moon, multi level disease, and she had treated the S f A at a prior time, but his ischemia had continued to progress She had seen in 80 legion at that time, but it was unable to cross it from an anterior. It was a single vessel runoff and worried about either m belies ing down that would cost him his foot. But there is no suitable vein for a bypass. The vessel was diffuse lee disease and so not great for access. Just primarily. And this is what I'm talking about. You can see here just from the plain films when you can see the entire pathway of the vessel from the calcification on X ray. That's slightly concerning to us and this here, you could see this calcium here. That's the origin of the 80. And that's gonna be our lesion. And so this is from a, uh, anti grade, uh, angiogram. And you could see the legion there and then also heavily calcified lesion right there on DSO. This is ah, Wheat Lander here from her surgical exposure actually got down to the anterior tibial itself directly access it that way she could repair it and, uh, not worry about either analyzing to the vessel or injury with the perky Taney iss axis. This is a retrograde shot, You could see it doesn't really go much of anywhere. Especially through this top lesion. Uh, treated this with a direct me to the bulk, some of that heavy calcium. And this was the result after after rectum is so pretty decent, but still pretty significant underlying stenosis there, uh, ballooned that Aziz a scene there. And the balloon actually expanded quite nicely, But there was certainly still Cem recoil in that area on dso went on to treat it. Uh, this is off label use because we don't have stents, their small for the peripheral or military. Um, yet, but this is a drug eluting coronary stent on. You can see a fantastic or is out there. Uh, this is our vascular surgery group. Currently, we have nine providers on. We're a big group. We all do. Pretty much all of vascular surgery on and part of I think what's special about us is Dr Hurl highlighted is outreach is very important. And we are surgeons to travel and these air the different locations kind of far reaching that we go up to Baxter, Cambridge Newam Fair, Bo Northfield, and then a little bit closer to home in the Metro here also go to several sites there and so were able to bring care and surgical care to patients who don't want to travel or can't travel frequently down Thio Abbott itself. So I want to thank everybody for their attention on I'm happy to field any questions at the end of all this and without. And he further ado, I will turn it over. Thio. Doctor Eckman. Good evening. I hope everyone can hear me. Okay, thanks to Dr Carolyn. Doctor Titus for the introduction. Um, tonight I'm gonna be talking about heart failure. Just see if I have control here. So I have ah, number of financial relationships to disclose of various pertinence. I'll try to highlight anything that might be of interest as we go through. Um, I have been a consultant with Abbott, the company, not just the hospital. Although I obviously work in Abbott Hospital, Medtronic and then have also been on an advisory board for Dex. Or, um, some of what I'm gonna be talking about tonight is investigational and off label on all the income that I get from these is donated to our foundation and I do not have any control over how it gets spent. So tonight I'm gonna talk about medications in heart failure. I'm gonna talk a little bit about monitoring. And then finally, I'm gonna talk a little bit about some of the different procedures that are either available now or coming down the pike in terms of things that might be of interest for heart failure patients. So with regard to medications in particular with heart failure with reduced ejection fraction, we've really seen a dramatic change in the therapeutic armamentarium that's available. And for a patient that has reduced ejection heart failure on no medication, they have a two year risk of death of almost one and three. And with contemporary therapy, including in the angiotensin receptor blocker and impress. Listen, inhibitor, beta blocker, mineral Kordic, oId receptor antagonist and SG lt two inhibitor. The risk is now down to one in 10 for these patients. Obviously, this is a number of medications, but this really takes, um, new onset Sistol cart fire from something that it has a prognosis on par with many metastatic malignancies to at least less worry some cancers. Um, probably the biggest. Uh, well, there's two medications that are really big stories in the reduced ejection fraction space. The first is from the Paradigm Heart Failure Study of Val Spartan and the Nepalis in inhibitors to Cuba. Trail Valse Artan is the air B that you all know in love and have seen used in other settings. The SECU betrayal is the novel component of this and this trialing was randomized against an Elop Rhyl and published of six years ago now and looked at patients with H A functional class two and three heart failure and saw significant improvements in the cumulative endpoint of heart failure, hospitalization and cardiovascular death. And both of these sub and points were also favorable. Um, the way this works and the SECU patrol in particular, what it does is it blocks an enzyme that Brock that breaks down natural peptides. And so this is a medication. And that in a sense increases the levels of the good hormones the endogenous natural peptides air helpful in they cause some degree of Aizu dilation and also natural recess. Um, I should mention, too, that this was studied for heart failure with preserved ejection fraction in the Paragon study, which unfortunately did not mean it's primary endpoint, although the P value was awfully close. Um, and so many people think that this drug may yet have a role in patients with heart failure with a preserved ejection fraction. But it's not presently indicated for that purpose. Um, I I would say that in in most, uh, heart failure based guidelines and in many people's practice, this drug has when it's not financially toxic, which it sometimes can be less affordable certainly than Valse are tan alone or other medications in this class, um, is has really moved to the fore in terms of treatment for heart failure patients. I will say that I have basically stopped prescribing ACE inhibitors other than in very select circumstances. One of the reasons for that is if someone is on an ACE inhibitor and you want to convert them to, uh, this combination medication, they have to be off the ace inhibitor for two days. Uh, similarly ace inhibitors do have some incidents of cough, which I think we all see, not infrequently s. So I think the role of a C inhibitors in the treatment of reduced ejection fraction heart failure are really is really fading. Um, the second drug that I think is really interesting. And this is ah, fascinating story. Um, that, you know, most of you may already know. Historically, if you had a medication that you invented for diabetes, all you had to do to get approval will show that it improved blood sugar. Um, this was important because that was thought to reduce risk of complications from diabetes. But then we discovered that some medications increased cardiovascular events, even if they made blood sugar better. The FDA then said, Well, if you're going to invent a new diabetes drug, you need to at least prove that it's not making cardiovascular outcomes worse. Um, that then leads us Thio the novel class of medications or relatively novel. It's, I guess, more novel If your heart failure cardiologists. Others have been using this for several years. Um, SGL t two inhibitors on the study that really was a bombshell in the heart failure community that was published just over a year ago was the DAPA HF trial of Dapa Cliff. Listen versus placebo. What changed this from a drug that in preliminary studies had been shown to have favorable outcomes from patients with diabetes who also had heart fire. They had reductions in some of these cardiovascular endpoints what was found when we then studied this drug in patients that had heart failure, even if they didn't have diabetes. And that's the really key thing that really knocked Everyone's socks off is that this is a medication that had a dramatic improvement. You can see the hazard ratio 0.74 The effect of this and some other studies have been suggested to to start to see these curves diverge within two weeks of starting this medication. And this was for the composite of cardiovascular death, heart failure, hospitalization and urgent heart failure visit. And again, the subgroups of this. We're also favorable. Um, so this was not driven by a Nen point exclusively like urgent heart failure visits? Um, so this was really a bombshell. The FDA finally granted approval for the indication uses for heart failure in May of this year. Um, this is something that in my mind switched this drug from being a diabetes drug. That's good for patients that have heart failure to now. This is an indicated drug for patients with systolic heart failure that Oh, by the way, if you have diabetes, that might make your glycemic control a little better. So this is now part of the four class A drug therapy that is indicated for patients with reduced ejection fraction. We do see some challenges with this. I've had some pharmacies, uh, call and ask if this was a mistake because the patient is does not have diabetes, have had some issues with prior authorization, and access remains a little bit of a challenge. But this is a class of medication that has really exploded onto the scene and reduced ejection heart fire. And it's something that we're using very routinely. What I'm finding clinically that's interesting is by the fact that this works by causing glucose Syria. Um, it's a it's somewhat of a diuretic, and there's a lot of data and discussion about what the mechanism is of why this class of drugs has been so effective. But on some level of diuretic effect has been a clear win. What I have found when I'm starting this medication in my heart failure patients is that I typically need to back off on their diuretics because otherwise they run the risk of hypoglycemia or hypovolemic Excuse me. The risk of hypoglycemia with this medication is actually quite low. And again, many on this call may have much more experience prescribing this than I do. But it's something that I think you're going to see a lot more of in the cardiovascular space, particularly flowy of heart failure. Um, as I mentioned the components of the primary outcome, this was not just driven by reduction and urgent hospitalizations or urgent visits. Um, you know, worsening heart failure events and, most importantly, cardiovascular death. I was also significant. Um, what I think also interesting is that the implementation potential of this is really, um, something that's important. And I think this is one of the next frontiers in terms of heart failure cares. How do we get the therapies that we know are effective toe all the medications that could benefit? It's been estimated that there's over three million patients in the United States alone, with heart failure through low ejection fraction. Almost 70% of candidates for this medication and the other part of this study that was notable was the DAPA HF study. Enrolled patients with an E F of 40% or less and they only had to have a GF are greater than 30. So it's also given us a lot of data and a lot of information on the use of this medication in patients with borderline renal function or renal function that was historically considered to be prohibitive for use of this medication, um, it has been estimated that optimal implementation of this could present prevent between 20 and 40,000 deaths per year. So this is something that really has a lot of potential. It's obviously just one medication in the tool box, but is a good example of how making sure that we're getting all the patients with reduced ejection heart failure I'm treated with the medications that we know are life saving. There's ah, well known anecdote of once it was figured out. Limes cause scurvy, but it took a long time to get the lines to the sailors to prevent scurvy eso we're trying to, and I think one of our priorities in the heart failure program with Minneapolis Heart Institute is really trying to offer access to help with medication Titrate Shin with our team of nurse practitioners, clinical nurse specialist and pharmacists to help with the implementation. These medications. Um, one example of this when we look at data from the Champ Registry from multiple centers 150 practices over 3000 patients. And when you look at what percentage of patients are on the medications and this is pre s guilty to inhibitors are on the right medications. I would say reasonable fractions air on the S, air B or air. And I, um, and beta blockers Very modest percentage on mineral Kordic oId receptor antagonists. Um, but what's most striking is a tiny percentage of these patients are on both the right drug and the right gold dose. And so this really highlights the massive opportunity that I think we have as providers of care to people with heart failure. And I think, you know, if we look at this and say, Well, what about if somebody had coronary artery disease and we had, uh, you know, 70% of them on aspirin, but they were all taking 20 mg of aspirin. We would be appalled if we had patients with hyper, uh, glossy mia and hemoglobin A one C of 10%. And we're not on treatment or patients with L. D. l of 250 who are not on statin therapy, For example, I don't think we'd let this stand. And so this is an opportunity for us to recognize and really work hard to improve the both the medications and the doses that air used. We've looked a little bit further at this data and and done some diving in our own data toe work on this. This is, uh, a subset of the data from this group. I think what's really key to see is that 12 months on Lee, very small percentages of these patients were having these appropriate medications increased or the doses increased. And at 12 months, less than 1% of these patients were on a target dose of all these medications. So this is a really a massive opportunity, one of the things that we've done recently I mean, this is less to do with medications, although our medication projects are also ongoing. We looked at the electronic medical record to, for example, see if we could identify patients that were eligible for but did not have a by ventricular defibrillator or by ventricular pacemaker. What's easy about this is eligibility is defined very easily by echo parameters of low ejection fraction and E k g parameters of a wide QRS. And we use this to identify almost 400 patients within the align of system that were eligible but did not have the device when we dug down into these. You know, they're certainly some flaws in this approach. Some fraction had the device, but it was implanted at another hospital or another system, so we didn't have a way to easily track that some fraction of these patients were incredibly elderly, you know, there were a couple dozen that were non vegetarians. There were some that were in hospice for other problems, some with active substance abuse. Eso This certainly didn't have, ah 100% hit rate, but we thought it was a good example of how we may be able to use it on leverage. The electronic record to identify patients that may have gaps in their care medications is another way that this could potentially be used. Um, a couple other medications I want to talk about briefly. The first is intravenous iron. There's a study that suggested that intravenous iron, which is absorbed better in patients with heart failure may have an impact on hospitalization rate and were part of a study looking at intravenous iron to see if that would be helpful. Uh, there was a study published a couple years ago about subcutaneous loop diuretics, particularly subcutaneous furosemide Lasix, which I think is really an exciting possibility. So many of the patients for heart fire are admitted predominantly for Ivy diuretic, so stay tuned for that development. Another one that's had a fair amount of attention is the use of two feminists for transport reading amyloid. I mean, this was really the first drug to be shown to have some benefit in this. For patients with this condition, um, decrease in the rate of decline of six minute walk test and decrease in the rate of decline in quality of life questions. Eso This is something that there's a least some hope for treating this condition. But one of the things Madam, our who's a cardiologists from Colombia who's been a world expert on this has also highlighted that the cost of this medication is is quite expensive and often can limit access briefly in terms of monitoring. Um, there's still a lot of excitement Attn least among the general public over things like the Apple Watch. E think it hasn't quite lived up to its potential yet, but that's something we'll hear more about. We also are seeing a lot more use of the cardamom sensor was, which is an implantable pulmonary artery sensor that we used to take daily readings of people's pulmonary artery pressures and help with diuretic. TITRA Asian of note. This is indicated both for reduced and preserved ejection fraction. This is based on data from the Champion Trial was published now almost 10 years ago, and all the graph on the left shows the decrease in pulmonary artery pressures over time. On the right, you see the hazard ratio for hospitalization and it cuts the rate of hospitalization about roughly in half. Post approval studies have also been done to see Can we recapitulate this outside of this type of a trial Again, we had almost half these patients had preserved ejection fraction and we saw the rate of heart failure. Hospitalization was dramatically lower and heart all cause hospitalization was also lower as well. Um, this is examples of how this, uh, was preserved across on the bottom panel here by ejection fraction, whether it's low, medium or essentially normal. And then the top shows the patients What was their rate of hospitalization or all cause hospitalization and blew the year prior and an orange after implant? A couple of brief procedures in the heart failure space that I think are of interest. Um uh, mitral valve regurgitation is a very common Medicaid. Our problem in patients with heart failure, particularly if they have a dilated ventricle. And if this is leaking despite being on guideline directed medical therapy, the question waas whether trans catheter repair or Mitra clip is the device that's currently most frequently used. What we found was that this decreases heart failure, hospitalization over two years and had a very good freedom from device related complications. Um, the way this is done typically through, uh, left atrial or interracial puncture, this little clip is then advanced across the mitral valve is synched up and then sort of left behind, almost like a staple. Um, what I think was really striking. Not only the heartfelt hospitalization all cause mortality thes air, really sick patients typically, um, and we found that their rate of needing a VAT or transplant was half what it was in. Patients did not have this treatment. Stroke rate was lower, and the change in both quality of life and six minute walk was also improved. So this is another therapy that has clearly become part of the routine Army material for reduced CF heart failure patients. This is an example of another device that investigational, where one of the sites that's been participating in this, it's a trans catheter device that is designed thio cinch up the heart not unlike a cinch on a purse string. Um, that can be done with a catheter and is a way to address mitral regurgitation without open heart surgery. Uh, and I'm here's another example of sort of what this looks like. It's also being investigated for the purpose of reducing the rate of L V dilation. I mean again, this remains very, um, experimental or investigational. And I should say I do have permission to share this, even though it says confidential on there. It's part of a trial that's ongoing so that confidential tags not true anymore. So please don't throw me in jail. Um, the next frontier in heart failure is a try. Custom valve regurgitate lesions are incredibly common in patients, and this is another area where trans catheter treatments are really exploding. Um, there's a number of different devices that are out there, the one that we've been involved in and had done. One of the first implants was the try illuminate device, which is a clip very much akin to the mitral clip. Um, one last procedure I want to mention in the heart fire space that's also investigational. That we've been excited to be part of is the idea of creating a hole in the heart or atrial shunt on purpose. The concept here being patients with increased left sided filling pressures but normal right sided pressures, which is incredibly common in people with preserved ejection. Um, fraction heart failure, um, is that it works like a pop off valve and the initial trials of this both. One example is where it is literally between left and right atrium. Another is between the left atrium in the coronary Sinus. The idea here be being that it's less likely that you'd have embolization that could cause a stroke. This is from the first approximately dozen patients that were implanted, you can see a baseline. All were N Y h a class three or four and and follow up, um 90% had decreased and watch a functional class one or two. So I think this is a new, exciting area of investigation for heartfelt, preserved ejection fraction. A couple of quick questions, comments with regard to heart transplant, intel bad. Um, I won't belabor this, but a couple of things that are happening One is the use of ex vivo profusion. This is an example. We refer to this as heart in a box. This is a way that instead of putting the heart cooler, as you can see from the graphic the bottom left where we literally put the heart on ice to transport it for transplant, we can now use this device and keep the heart beating and, uh, oxygenating eso It's extended the time that the heart could be outside of the body for transplant. Where this also becomes important is that historically, we've only done heart transplants after brain death. But now that this is an option, um, people can be permitted to die a cardiac death and the heart can then be procured and potentially resuscitated on this device. Um uh, does not always work, but even if it works a fraction of the time, that's one way that we can increase access to devices. Um, this is not yet approved for use Has been investigation. We've been very proud to be in the trials for this as one of the very few in the heart in a box and the only non sort of major academic university Associated Medical Center with the donation after cardiac death trial. The other thing that we've been now doing is now that hepatitis C is curable. We're now generally pretty willing to accept donors from hearts. Uh, heart donated hearts from patients that had hepatitis C, and that's also opened up a new avenue of access Thio organs for patients that need them. So I'll stop here and leave you with a picture of the wall of donuts and would be happy to take any questions. I hope you've enjoyed this, uh, summary tonight. Thanks very much. Dr Titus and Dr Hoffman. I guess we will start our questions with Dr Titus. Does MH I have any specific protocols for abdominal aortic aneurysm or other vascular emergency specifically for E. M s and pre hospital care like they do for M I or stroke. We do on the on the MH I app actually is easily available. We have one for Justin aneurysm protocol and then dissection protocol as well, because those treatments do differ and then the Thirdly, we have a critical limb ischemia and acute limb ischemia protocol that just helps guide you on what medications we recommend. Any tests we want done, or any any labs we want checked before you send them. Perfect. And second question for you as well Is lifeline community based screening acceptable sufficient to screen for karate disease? I'm sure you hear this one a lot. It is. I think Lifeline is actually quite helpful because usually it's free for the patients, is run at, like their local church or something, and it gets people to us. I'd say the one difficulty with it is sometimes the ultrasounds aren't of or at least the reports. It's hard to get the images for us, and we love to look at images as surgeons. And so we get the report, and sometimes the reports aren't complete, so there's a chance we have to repeat it. But it does. Does a good job of identifying significant disease and getting them to a place where they can undergo more kind of robust and in depth work up. But also, when the patients get the results, it does kind of cause them a lot of concern because they just get a letter in the mail saying you have peripheral vascular disease or you have stroke risk and they kind of freak out. And so I think it's useful. But it should come with some interpretation. Thanks. Remember, you can push the Q and a button at the bottom of your screen. Thio add. Add any questions. I have one. I'll ask for Dr Eckman. I found your comment about utilizing intrest. Oh, is kind of a first line medicine. Intriguing. I recognize that for some patients, it's cost prohibitive. So I'm interested in your second line medication, assuming that they cannot take in trust, offer those financial reasons. Would you go straight to Valse Arden? Or do you feel there is still a reason to go to listener pro before Belle's heart? Um, in my experience again, I've largely stopped using Listen, a pro. I mean, if someone's been on it for years and they're happy with it, I am not necessarily going to change it just on that basis. But if if you know, entrust Oh, or psycho patrol Valse Artan is not an option either due to cost or, you know, some patients feel worse on it. It is a more potent anti hypertensive, and so some patients with borderline blood pressure don't tolerate it. Well, I do go toe RBS as my next line. So I you know, I used belts. Artan. That's a B I. D. Drugs so often I'll use low certain. I often find myself using even low start and or can dishearten, for example, on a you know, half does B I d basis just to spread out the peak. Effective it, especially many of our patients, is we're trying to uptight up titrate their medications have problems with, you know, borderline blood pressure, a lot of light headedness in the middle of the day. Eso I'm not saying people shouldn't use Listen, a pro capital pro Loren Ala Pro. I mean, those drugs clearly do work and have a good data for them, but just in terms of the ease of switching to interest toe on DMA nim izing the risk that you're gonna have someone not take their medication because they're having side effect of a dry cough. Um, which can be insidious. I actually have a funny story about this. Several years ago, I was started on my Sina pro for hypertension and was in clinic and clearing my throat nonstop. And my nurse at the time who didn't know I was on and said, You gotta quit taking that lace. Interpol and I stood there and felt like a total idiot for 10 minutes. I e Barb, you're right. I am on my center pro. I guess I have to change it. So I didn't even notice it when I had it myself. So I think that's part of what's had me at least aware of the fact that it can be a quality of life issue. And now that there's not a significant cost difference for at least the the generic Air B s. That's a lot of why I have shifted to that. Yeah, I mean, I think you're right, that a lot of times it's the spouse is to bring up the lights in April. Issue is more so than the patient. How about what's your what's your kind of anecdotal experience within Presto and, um, Hef path with your preserved ejection fraction? So that's a great question, and I would say that it's an expensive medication if you can't get it covered. Um, and the official data does not support it, but I will say it's a good anti hypertensive. It has some good diuretic effect. And if I had heart failure with preserved ejection fraction, I would pay out of pocket and take it, because I do think that it has some benefit, and I think that it's a safe drug in that population. But I think, you know, I wanna be very clear that this is very much an off label thing. I'm not paid by no of artists. I have no relationship with them, but I think the data was close enough that if you're going to say a p of 0.6 in a condition that otherwise could be really challenging to treat, um, what I've seen anecdotally in patients with reduced ejection fraction is probably 20% of people feel dramatically better on it. You know, maybe five or 10% of people have whatever problems and need to stop it, and probably 70% don't notice much different. Um, I haven't had enough experience, and they have path population because the fraction that haven't want to do something that's kind of off label and have the finances where they don't mind paying $400 a month for one of their pills, um, is a pretty small population. But if it were me, I might try it. Okay. All right. Thanks. Oh, good. Um, next question, Do you have any thoughts on new polls the new entry Arctic blue pump that patients can go home with? Great question. So new polls, Actually, one of my good friends from college was one of the engineers working on that technology, and we had a good laugh. We said there must not be very many interesting problems left in the world if we both ended up working in the heart failure space. Although obviously there's still a lot to be addressed in other areas. Um, you know, it has had some potential in the preliminary data on it has been, uh, you know, favorable most of the experience or a lot of it has been from the University of Chicago, where one of the surgeons there was one of the main inventors in it. Um, you know, I think the role for it is probably limited in the sense that it provides ah, more modest amount of support than what you see with Anel VAT and I should just comment for those that don't know what the new pulses ITT's. Basically, um, it's It's sort of a cuff that goes around the aorta and almost works like a It's sort of like an intra aortic balloon pump. Um, and so on. Lee, it's not intravascular on DSO. This is a device that provides some additional support, not at the level you see with Anel VOD on DSO. For the patients that are really sick, it may not be providing enough support. Um, it may have more of a role, and I think the studies you know on what's been published is pretty limited so far. But it may be a way thio provide that kind of, um less intense, um, support than what you get with Anel VOD and may have some advantages in terms of reducing the risk of the complications that we see with intravascular devices. So that's one you know, stay tuned. We we probably we'll hear more about the new pulse in the next few years. All right, Next question about the air B is the data better for air B over ACE inhibitors for heart failure with reduced ejection fraction? Are you using the air B so that you avoid the potential for cough? And I think that's a question we just covered there a few minutes ago. Yeah, I want to be. I will add one thing to that. You know that the data on Ace's inhibitors is incontrovertible. That was sort of the first class that was that was really studied and clearly established in this population. So I'm not imputing the quality of the ace data. Air bees have generally been found to be equivalent to S inhibitors. There have not been found to be superior. Although the set Cuba trioval certain has been shown to be superior. Um, and much of my preference to avoid ACE inhibitors gets to avoiding that 5 to 10% risk of people that have cough. And because so many of my patients. I want to switch to entrust toe. Then it avoids that 36 to 48 hour washout period. So it just makes the logistics if I make that switch later much easier. Gotcha. Okay, well, see, no more questions. I want to thank everyone for attending and participating this evening. Um, keep in mind that we have an upcoming program in December, and the Q R code is now on the screen for you. And also, you will be receiving an email s so that you can get your CMI credit and complete the survey. So thanks, everyone and have a wonderful evening. All right, Thank you.