Cardiology Session: Heart Failure - part 3 | Hussam Alkhalifamohamed



This on-demand teaching session is perfect for medical professionals looking to learn more about heart failure. It will cover essential topics such as the cardiac cycle, cardiac output, pathophysiology, compensatory mechanisms, and different types of heart failure. Participants will have the opportunity to interact with the presenter, as he will ask questions and pick on people to join him on stage with their microphone. The session will also cover topics such as ischemic heart diseases, hypertension, and cardiac myopathies. Attendees can gain valuable knowledge and an attendance certificate at the end.
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Please Note: As this event is open to all Medical professionals globally, you can access closed captions here

This is our second teaching with Hussam Alkhalifamohamed, this will be interactive with lots of questions and learning.

You can find his previous event right here:


None of the planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Dr. Alkhalifamohamed, faculty for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Learning objectives

Learning objectives: 1. Understand the concept of cardiac remodeling and the associated vicious cycle. 2. Explain the differences between systolic and diastolic heart failure. 3. Describe the common compensatory mechanisms used by the body to counteract heart failure. 4. Identify the three most common causes of heart failure. 5. Explain how various underlying conditions can cause cardiomyopathy.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. Sorry about that tiny delay. Um His um had some emergencies where he was at. Um So we've got him backstage. He's here with me, er which he'll be delighted to know this will be recorded and it will be shared. You can follow, I have put his um's link um where you can just follow him specifically and you can see his other two heart failure events there. As always, this is gonna be interactive. This is super interactive. He I must be the most interactive person that I have on medical education. So if you would be happy to join us on the stage with your mic and came off so that when he asks a question, you're ready to give an answer. You can turn your microphone on, please just pop join in the chat and I'll invite you onto the stage. You can still use the chat if you'd rather if you don't wanna come on, that's absolutely fine. You can still use the chat and write your answers and your questions there. But if you're happy to join us, you'll see something on your screen that says join stage, you click on that you join with your mic and came off anyway. So it's not like everyone's gonna suddenly see you and then you can just turn on your microphone when you want to ask or answer a question. OK? I will be picking on some of you as well. If you don't want to join the stage, that's OK. Just ignore it, ok? But if you're happy to come onto the stage, just click join and then you'll come onto the stage. Alright, again, at the end of uh the event, you will have um your feedback form in your inbox, complete the feedback form and your attendance certificate will be on your medal account. Um And that's it. I think I can pass you straight over to his now who I think has settled himself and he's raring to go remember it is interactive. He does expect you to answer. Ok. Over to you Husam. Yeah. Thank you. So, hello everyone. Good evening from here. Sorry for being late. I just had some emergency. So, but the good thing is Susette. We are finally here. So I first to make sure, are you able to hear me? Well, all of you? Yeah. Ok. So let's go. Uh and the last two sessions we talked about started to talk about these important topic, heart failure. And we talked about the all uh basic uh stuff like how the heart contracts the cardiac cycle and some uh of the action potential. And the ECGS. OK. And also we talked about cardiac output and what determines cardiac output and how cardiac output is being controlled inside our body. And we just have a few tips on examination findings that could help us in heart failure. I also started to talk about the pathophysiology of heart failure last time. And, and we said that regardless of the cause of uh the heart failure, at the end of the day, we have uh decreased cardiac output. So the heart is stopped. Uh doesn't this function and the main function of the heart is to get blood. And, and this accomplished through two functions that the heart needs to contract and needs to relax at the same time. So it's to relax, to receive blood and it's uh to, to inject that blood, that heart received. Ok. And was that the heart failure could be from the left side of the heart. So the heart cannot get the blood from the left side. We know that the left side, the left ventricle, it gets blood to the systemic circulation could be from the right side of the heart and the right ventricle, it gets blood to pulmonary circulation or could be from both from both uh sides of the heart. Ok. And also he said that it could be systolic, that means mainly uh contractile dysfunction or could be diastolic, mainly relaxation, dysfunction. And regardless of the type of the heart failure, you have four heart failure that uh that when the heart fails to inject blood to systemic or pulmonary circulation and backward failure that because this blood uh cannot be injected, so it will be back pressure either on pulmonary circulation from the left side of the heart or systemic circulation from the right side of the heart. Also, we talked about the compensatory mechanisms and we talked about remodeling. Can anyone remind me what, what remodeling is? You can talk, you can write it's OK. It doesn't matter if you get it right or wrong, we can just try to interact. That's a remodeling. OK. Against the heart in terms of intru. Yes. What is remodeling? OK. We talked about all these neurohormonal uh compensations, the compensatory mechanisms that even when the heart is failing, it can help maintain the heart functions for a while. OK. And this um i it start this uh sy mechanisms usually start uh vicious cycle. For example, we have one of the most important mechanisms get through, get through the brain and, and the strong system. And uh that uh it will be 10 to 2 has many functions like physical constrictions, stimulation and Ron secret. OK. And all these uh commis mechanisms in the long term lead to, to heart to compensate either by hypertrophy and or dilatation of the heart. And also there will be many changes in the genetic level as a genetic level. And that uh the end of uh the end would lead to uh uh would lead to uh uh some sort of decreased blood supply to the muscles. For example, for all, you know, when there is hypertrophy, there will be some uh increased demands of the heart muscles. Ok? And, and this will lead to, can lead to ischemia and necrosis and fibrosis and fibrosis as well. OK. And that's what remodeling is. That's what remodeling is. That's one thing that, that we don't want to the heart of all patients. OK. And after remodeling, usually there will be some decompensation. Decompensation can occur in long term as chronic heart failure or can occur in patients who has this compensated heart failure and has some acute uh insult that leads to decompensation. OK. So I think that the last thing we talked about last time, yeah, it won't, it won't be in a long session. OK. So let's go. As you remember. Um we said in the middle of the picture, we have the heart failure that may produce called the output. It's called the output will uh stimulate a lot of neurohormonal activation, including sympathetic nervous system system and many, many, many hormones and uh neurohormonal mechanisms. OK. And uh at the end of the day, it has, we have vasoconstriction. Physical restriction can occur from detention too can occur from so the stimulation and other vasopressors. So the m retention mainly from aldosterone and this leads to the uh increase after look, increase after look. And that will affect in the long term will lead to further reduce in cardiac output. Ok. And then this lead to increased BP and cardiac workout as well. And also the retention will lead to increased intravascular volume, increase preload and afterload as well. And I also need to call the workout in the acute settings. This usually leads to compensation. This should lead to compensation. But chronically, there will be my sight loss from uh necrosis. And then then every time you have necrosis and death of myocardia, my my sides the repair will get through fibrosis, regeneration through fibrosis. And this is just a little bit heart failure even more. OK. This is a more detailed picture to show you all these um compensatory mechanisms. We have the decreased card put at the uh at the top of the picture and it's increasing beside the inclusion of the system and all the details shown here. OK. Um So at the left of the picture, uh if you screening, you see that um either the heart has to eject the blood against, OK. Against it. Uh reduced com uh either reduce the reduce compliance or reduced contractility, right? Reduce contractivity, reduced contractility may result in systolic heart failure and reduced compliance mainly leads to diastolic heart failure. Ok. So the heart either to get the blood against high volume or high pressure or high pressure. OK. High pressure. So that, that's the difference between systolic and diastolic heart failure And what do you think is more common systolic or diastolic heart in general? Yes. Ok. Ok. What do you think is uh is, um, it's easier to treat you? Of course, heart failure uh is difficult to treat but in general, which, which one is easier to treat? Is it a systolic or diastolic? Why systolic is easier? Why do you think so? Ok. Interesting. So we have systolic heart failure or as you see in the abbreviation risk that mean heart failure with reduced ejection fraction with reduced ejection fraction. OK. Or there is diastolic dysfunction or is this as you see if, if heart failure risk preserved ejection fraction, preserved ejection fraction. Ok. Yes, there is decreased compliance and here there is decreased contractility, decreased contractivity. We'll talk uh on that later on in more details. OK. And the doctor is relatively hard. OK. Dress 0.5. See. So this uh depends on the cause of the heart failure. There either will be hypertrophy or little bit, a little degree of hypertrophy is more dilatation. OK. And the left side, this is the normal uh in the, in the middle, this uh like the normal heart. So the hypertrophy is it could be uh it depends on how smes are being added. For example, if you have heart failure, secondary is ss systolic hypertension is different than heart failure. Uh hypertrophic second, systolic hypertension is different than hypertrophy due to cardiomyopathy. For example, hypertrophic cardiomyopathy. So, he has a uh the sarcomeres are added uh differently and that as a result in can result in hypertrophy or dilatation plus some degree of hypertrophy. Ok. Some degree of hypertrophy. Um So what do you think? What, what are the most common causes of heart failure or what do you think can cause heart failure in general? Yeah, you can talk at any time. People. No problem hypertension. No, I cannot hear anyone. Make sure you unmute yourself. Extent hypertension, increase systemic resistance, increase systemic resistance. From what? What? Pulmonary disease, uncontrolled ation, ation, aortic stenosis. Ok. Ok. M I Yeah, don't forget about m I never have ischemia. Ok. Cardiomyopathies. Ok. That's good. What can cause cardiomyopathy? I can cause cardiomyopathy, anemia, p edema causes carpal monal. Anyone wants to comment on that medication or meningosis pregnancy, pregnancy by itself is very rare or very likely to cause heart failure. But if there is some pathological condition, uh running through the heart before the pregnancy, pregnancy c has to be. Ok. Ok. The cardio. Yeah. Sure. So we have a lot of causes of heart failure that cause a lot of causes of heart failure. Many, many things that can cause heart failure, but the three most common causes. The top one in general is ischemic heart diseases, ischemic heart diseases and ischemic heart diseases. Uh ischemic heart diseases. It's not the M I, not only the mim I can cause acute acute and chronic heart failure of course, but also don't forget about chronic ischemic heart disease. For example, someone if it has uh chronic stable angina, it's the long term can result in chronic heart failure. Ok. So, ischemic heart disease in general is the most common cause of heart failure. Ok. Hypertension. It is considered the second most common cause of heart failure, hypertension and the delicious effects of hypertension is the left ventricle usually lead to uh uh heart failure as well. Ok. Vascular heart diseases, vas uh sorry, valvular heart diseases, valvular heart diseases. Ok. Including mitral stenosis, mitral regurgitation, ation, and less commonly, right sided uh valves as well. Var heart diseases also can cause heart failure. These are the top cause of heart failure worldwide. But as as there, there are many, many things that can cause heart failure, including endocarditis, including cardiomyopathies and so on. So many causes of heart failure, many causes. So how to classify heart failure? Let's go back and tell me how to classify heart fail, right and left. OK. Right and left. OK. Uh Just let me go back. I saw, I see atherosclerosis here. A scleroid is not caused. Uh It is not considered uh a disease by itself. It's a pathology that can lead to diseases like or can lead to skin a heart disease. So a story not considered disease by itself. Ok. OK. Uh For and back or knee head classification. What do you mean by knee head classification called the ejection fraction. What? Uh ok. What do you mean by call it ejection fraction? Decompensated, compensated. Ok. It's called diastolic. What do you mean by any classification? Font, acute and chronic? Yeah. Sure. Ok. So left-sided right-sided. Still in the stomach compensated. Compensated. We have classification as, as their physical activity. Ok. Good, good. Keep this in mind. We have classification. We talk on this most likely next time and it's very beneficial for your patients. When patient presents with symptoms of heart failure, you should put the patient near classification. OK? You should because it's it's uh clinical. Um it's clinical uh locations is are very important. OK. So here we are talking mainly about the pathological classifications of uh of uh heart failure. So, heart failure is used to be uh classified as left-sided heart failure, right-sided heart failure or congestive heart failure. Which one is the most common is the left or right or congestive mi Yeah, left-sided heart failure is more, most more common than the left, rightsided heart failure. What is the most common cause of left-sided heart failure? Uh Don't just say m I it's ischemic heart disease. Ischemic heart disease. Ok. Because even chronic ischemic heart disease can lead to heart failure. The most common cause is ischemic heart disease. Second, most common cause is hypertension. Ok. I know that is the most common cause of right sided heart failure or left with right ventricular failure. Yup, right sided heart failure is most commonly caused by right left-sided heart failure. Why is that? No father, the compensation is not, it could, but it's not the same as right and left side, it hurt. Ok. Left sided heart failure leads to BP of BP in the right side of the in the lungs, pulmonary circulation and that chronically leads to pulmonary hypertension. And when you have pulmonary hypertension, that leads to BP on the right side of the heart. So now the afterload of the right side of the heart is increased. So, uh long term also, and heart failure, the most common cause of right sided heart failure is left heart failure, which is the second most common cause of right sided heart failure. No sarcoma can cause s right side heart failure or pulmonary pulmonological conditions. Pulmonary conditions that can lead to most likely to pulmonary hypertension right ventricle over so hypertension. No, it, if we won't understand this, we should understand the cardiac cycle. So the the right vent, right atrium ejects to right ventricle, right ventricle ejects to pulmonary circulation and pulm is from patients to the left atrium and then to left ventricle and systemic circulation. So, from right ventricle to pulmonary circulation. So if there is overload on the lungs, that can back up on the back, uh cause back pressure on the right side of the heart and not vice versa. From right side of the heart to systemic circulation, not vice versa. Ok, So uh overload on the pulmonary circulation can lead to pul to right side. Uh right side, right ventricular overload and overload on the left ventricle ventricle or left ventricle overload can lead to pulmonary hypertension. Ok. So most common cause. Uh second most common cause of right heart failure is pulmonary conditions that usually lead to pulmonary hypertension and that back uh leads to back pressure on the right side of the heart. So what do we call this condition when we have right heart failure, secondary to lung disease, usually secondary to pulmonary hypertension from lung disease. Yes, we call it corporal coral corp e corporal monae. Ok. Uh usually it starts on 11 ventricle and that lead uh and uh chronically it affects the other ventricle and usually it's, we call it congestive heart failure, congestive heart failure. Ok. We're gonna talk about the clinical uh manifestations of each one later on congestive heart failure. So, we have left ventricle or right ventricular, usually affects the other side. Usually it's left ventricle than right ventricle and then congestive heart failure. Ok. Regardless of it's right left or right or congestive, it either could be acute or chronic, acute or chronic. And this is, I don't, I think this is uh self inflammatory cause acute, that means acute insult leads to acute decompensation of the heart and at least acute heart failure. And usually patient presents with severe symptoms. Uh usually patient present to the er at the emergency department. Ok. And patients need uh many patients need ad admission to high dependency and it or even ICU. Ok. And chronic usually this is, this builds up over time and patient presents with progressive symptoms, progressive symptoms can be, can be asymptomatic can be mild, can be moderate, can be even severe. Ok. This is chronic and some patients have chronic heart failure, chronic heart failure over time, it's decompensate, it's compensated Patients have, doesn't have any symptoms or have just minimum symptom has minimum symptoms. And when there is acute insult of care that can lead to acute and chronic heart failure from which patients either can become symptomatic uh synthetic all the time or can even regress to basic basic uh uh level and then can appear many results. For example, patient has cardiomyopathy, it's compensated and then has mm I OK. And then M I occurs like leads to a case of chronic heart fail. Then II treat it early on, must treat it early on and the patient requests to basal basal function level. Ok. So it could be acute, it could be chronic, could be acute and chronic. And then we have the most recent classification but the most beneficial one, most beneficial based on ejection fraction based on ejection fraction. How do we classify heart failure based on ay fraction? Yes, heart failure with reduced ejection fraction. This is usually systolic heart failure and heart failure with preserved ejection fraction. This is usually diastolic heart failure. Ok? And there is some uh some between because it depends if you have ejection fraction, more than 50. Since this, we call it a heart failure, it is preserved ejection fracture. If it's less than 40% this we call heart failure is reduced ejection fraction. So there is some uh one spectrum in between, in between between 4050. And this we call it heart failure with improved ejection fraction, it's not reduced, it's not preserved, it's improved. OK. We'll talk about this also in clinical manifestations in and in, in management, in created details. OK. Up to here. Anyone has any question, anyone has any questions? OK. The last classification is the usually with heart failure, there is reduced car output. It's called reduce out serotypes according to fraction. Uh heart failure with reduced ejection fraction with improved ejection fraction and in between uh sorry with a preserved ejection fraction and in between with improved ejection fraction has reduced preserved or improved. OK. Or yes. OK. Uh So uh low, usually cardiac heart failure is usually associated with low cardiac output. But there are some forms of heart failure which have high output or high cardiac output. What do you mean by that high output heart failure? What can cause high output heart failure and why? What's m to make sure that everybody knows T OK. What else? Hyperthyroidism? OK. Every a venous malformation pregnancy can lead sometimes to high heart failure. Ok. Anemia. Ok. Else you are missing something. All these are outside of the heart. There are two, at least two conditions of the heart can lead to can lead to high heart thos of course, which found the lesion gonna drop toxicity. No, I don't believe so. No, not II with cardiomyopathy when I feel it, I don't know. So there d toxicity. Mm. Why do you think can cause a heart failure? What is the BSI behind high of the heart failure? Yeah. In general, with some exceptions. OK. There is uh increased. OK. There are several, several mechanisms. The most common mechanism is that the increased metabolic demands of the peripheral body, increased metabolic demands. For example, in thyrotoxicosis, in pregnancy, ok. In anemia, there is an increased metabolic demand from the, from the, from the body. Ok. So the heart has to function even more uh to eject more blood. Ok. Exactly to increase cardiac output. But in short term increase cardiac out. So the heart has to function has to contract, has to work out more than it should. Ok? But in long term, you, this results in cardiac exhaustion and this can lead to heart low out heart failure as well. So, and it uh long term usually this comminate in low heart failure as well. So there are many causes, pregnancy is one of the causes hyperthyroidism or thyroid cause cause one of the causes anemia, severe anemia. Uh my aortic regurgitation and sometimes severe regurgitation cause obesity, especially or morbid obesity can lead to I output heart failure. AVM, renal failure by itself. No. But for example, patient has uh patient is uh underwent AVM for hemodialysis. This can lead to higher heart failure. Ok. High blood, the mechanisms are different but the most common mechanism is increased demand. So it's a preferred circulation with a preferred circulation. Ok. So the heart has to function more But this is not the mechanism in the religion is not the mechanism in obesity, for example. OK. And also in AVM. So this is the difference between high and low output heart failure. And we in our talk, we're just gonna focus on the output heart failure. OK. So any question up to this point, any question, not just on the points we we we discussed today even on earlier sessions cause it's all connected. OK. OK. So as we mentioned, there are many, many causes. OK. Uh certain drugs can cause heart failure, mainly chemotherapeutic agents, some chemotherapeutic agents, many rheumatological conditions or conditions can cause heart failure. Many endocrinological, we just mentioned thyroid. OK. Uh cardiomyopathies can lead to heart failure. Heart failure can cause arrhythmias and arrhythmias can cause heart failure as well. OK. OK. We mentioned uh hypertension infiltrative heart disease as some of you mentioned amyloidosis. OK. And another infiltrative heart disease. Usually this lead to what is called restrictive cardiomyopathy. Some can lead to even have uh dilated cardiomyopathy and, and it can lead to heart failure as well. Myocarditis like myocarditis, myocarditis can be part of um can be isolated usually from viral causes. Viral myocarditis could be uh or could be part of rheumatic heart disease. Ok. Um Peripartum cardiomyopathy, stress cardiomyopathy, as one of you mentioned, that could. So, so that could and, and these are just also examples, not all the causes of heart failure, so many, many causes of heart failure. But at the end of the day, at least remember the three, the ischemic heart disease is hypertension and heart disease. Ok. I heart disease. Ok. So any question is it all clear if it's there is no question. Just at least try it please to be sure. OK. Ie thank you, Ala sore of here. OK. So OK, thank you. Call ITA. So we talked about the pathology of heart failure. We mentioned the all the mechanisms that can help to maintain cardiac output uh for a while. And then we mentioned the remodeling of kind of care and also the classification of heart failure and the most common cause of heart failure. So let's talk about the clinical features of heart failure. You finally got here. OK. We said heart failure could be acute or chronic, right? Could be acute or chronic. The the clinical features depend on the chronicity of the heart failure, a diabetic heart failure. OK. That's interesting. Generally speaking, we go through the yep, we go through the e everything that could cause heart fail depending on the scenario. And uh when we don't find anything, we go to develop heart failure. That's interesting. Thank you for the coach. Ok. So uh it depends on acute or chronic. Heart failure, depends on acute or chronic. Um What do you think acute heart failure usually presents to us edema where is near malation, shortness of breath leg again? So it is near, OK. Exercise intolerance, edema. OK. OK. First, when you ask, when you ask such question, you need to make sure it depends which part of the heart is affected. Is it the left side or the right side of the heart? And most commonly, it's the left side of the heart, but it could be right side of the heart could be both. Ok. So if it's left side of the heart, there are fluids will back up on the lungs. So they will, they will be pulmonary edema with or is that pleural effusion? OK. Edema with or is that pleural fusion? And this can lead to severe shortness of breath? Severe diz OK. Usually patients cannot lie flat. OK. And could the cyanosis can, can occur or not? Usually depends on the cause more than the heart failure itself. OK. And uh there could be some pal palpitations. Ok. Also it depends more on the cause. So there are features of acute heart failure itself. Plus features of the course. If it's the right side of the heart, then there'll be uh the heart, the fluids will back up on the systemic circulation. Could be some fatiguability, shortness of breath kind of. But usually it's not that severe as since I left sided heart failure, usually there is peripheral edema. It could be on Xanax. It could be some if, if the patient is not mobile, if the patient is not uh is uh down a bit, there will be what's called an edema on the sacra. OK. Could be some hepatosplenomegaly or hepatomegaly at least. Also venous gestation, venous gestation. Ok. Uh So it depends on the right or left side of the heart. It depends on the cause as well. It depends on the cause as well. Usually a patient present with acute heart failure, presents with symptoms that started severely, that progressed over one or two days and presents with uh severe shortness of breath or severe fatigue ability. And plus minus the cause. For example, if the cause is uh my, my my coral ischemia patients present with chest pain. Ok. And then you do the examination and the exam. What do you suspect the pulse to be in acute heart failure? No binding bulb bonding pulse is even increase. Uh usually in hyperdynamic circulation, bounding BS but usually it's tachycardic. That could be bradycardic. Also, for example, if that causes Perth, if it causes myocardial ischemia that affect affects the. Uh no, it could be bradycardic. OK. But usually it's weak BS tachycardic B. What do you suspect give B B2 B regular pressure, normal increase. Also depends on the side of the heart failure. Usually left side heart failure give, even if it's increased, it should not be like in the right side heart failure, usually it's normal or just slightly increased, but right sided heart failure really is markedly increased, it's markedly increased. Um What about the heart sounds? I will get back to you. Just finish with the exam. That was a hard time. I expect to be some sort of history. Ok. And if there is chronic condition going on, there could be some four as well. Ok. What about lungs? Oh, don't forget there could be some memory. The cause for example is uh at the uh valva lesion or infective endocarditis. Ok. Usually there is fine crackles, fine crackles by basal cations. Ok. Uh ok. What about the abdomen? Could be normal? Could be there is Hepatomegaly or hepatosplenomegaly and could be also some, some. Ok. Some uh it's a question of run ask question. Yes, because the reflux will come to that. Why is the bus could be DYC cardic? It depends on the cost. Um Sometimes for I just, I just give you the same example. Myocardial infarction can affect according to which vessel is affected. If it affects the vessels that supplies the Acular no, every node. Ok. That can result in bradycardia. It can result in bradycardia. It affects the uh usually that affects right side of the heart. Ok. So for example M I from the right sided right ventricle, usually the affect of the node can lead to brady heart. So the cost can lead to bradycardia itself. What is, what is about the regular reflux? Yes. For gay baby, it's more than four centimeter kind of care on a kid. Heart fail, especially if it's severe. Ok, especially if it's severe. And also there could be some tender hepatical. Grace gave me a pressure on the liver and why? Yeah, because you just increase the back uh the venous return to the right side of the heart. Ok. And then increase it from the from below the heart. So the the blood has to back up on the above the heart. That's why they they many times it is positive he reflux and please don't forget to ask the patient when you are going to do uh he re reflux as the patient. Do you feel any pain? Many many people forget that. Ok. Uh OK. So far so good. This is just uh an introduction to the clinical picture. The clinical picture is a heart failure. Next time we're gonna discuss it in more details, in more details. Ok. Um Do you have any question? Ok. Ok. Next lecture looks like um ok. Um I will try not to try to be, we will not commit yet. We'll we'll let them know. Yeah. Yeah. But try not to be later than the next week. Ok. Ok. So please go, go review all the things that we said, especially in the part of histological part of the heart failure. And of course, if you have any question any time, don't forget just to, to text me here. Ok. So does anyone have any questions? Is that you done Sam? Yeah. Yes. Yeah. Ok. So does anyone have any questions? Any other questions I thought I saw was this something somewhere that you said you would come back to who asked a question that I thought you said you would answer? But yeah, that, that was a question about the Bradycardia and I II that that question. Yeah. Yeah, perfect. See, I am not medical. So yeah, the the measurement is it four is more than four centimeters because you have the five centimeters of the right atrium, the depth of the right atrium is suggest. So it's four centimeters plus the five centimeters that may lead to nine centimeters above than that. It's, it's positive. Ok. It's increased anybody else if anyone is on the stage and they want to unmute themselves and actually verbally ask, then please do um love to have you ask a question. OK. You must have answered all their questions and she went along. Yeah, no more questions. Anyone it's a quiet start to the week. Yes or maybe not for you because you've been busy today. Ok. So I'll just let everyone know um, at, er, on the hour when this event has been running for the one hour, you will get a, er, feedback form in your inbox, complete that feedback form and you will then get your attendance certificate on your medal account. Ok. And s asking another question. Yes, of course. After we're going through the clinical features and diagnostics. After that, we're gonna spend a lot of time in the management. Perfect. And if you follow, um if you follow Hussam, you'll be able to see some of these things as well. And if you just follow er, medical education, you'll be able to see on there as well. When we've got an another event, we'll try and pop them up quicker. Sorry that there was a little bit of a delay. The delay was my fault. I read his email and then I forgot to get back to him. So the delay was mine in this event happening, but hopefully we'll be quicker next time in uh organizing the next event. But bearing in mind we do have Christmas. Ok. Ok. Um Rana Rana uh management A IEC is the best treatment Sam? Just AIC E. Ok. Uh That's a good question. It will be answered at the end of the sessions of the heart failure. So what, what do you think about next time to tell us since the start of the session? About a little bit about your insurance? Was it run OK. And I can comment after that. Perfect um for those uh who want part one and two of heart failure. Um Let me find Hussam again. I'm gonna put Hussam link into the chat and you can actually follow him and that's where his other two cardiology, heart failure sessions are. Ok. So you can get them there and they both come with a ca they it's catch up and it comes with a feedback and certificate. So you can still get a certificate for those two events. Um, if no one's got any other questions, although lots and lots of thank you, Sam. Uh If no one's, oh, thank you. I got, yeah, this is the one you should be thanking for organizing such a incredible website. And so we will say goodbye. Um, er, and, er, like I said, keep an eye on metal education, keep an eye on who Sam followed him on, on Medal and on Twitter as well. He's on Twitter and he's very active there too. So you can follow him there and he'll advertise the events as and when they come along. All right. So we will say goodbye, please fill out your feedback form and I will forward it on to his um, as well. Ok. Take care of everybody. Ok, see you. Bye.