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Hello, everyone and welcome to medical education. It's great to have you here today. Uh We have Hussam joining us again about cardiology and I was just telling uh his and George who's backstage with us too, that we currently have 99 countries following me education, which was created to help doctors and healthcare professionals like yourselves continue their education with incredible speakers who we have on the platform. So we're delighted that we've got 99 countries. We've got a hun 1561 followers. Amazing. Anyway, as always, this is an interactive session. Um What I am gonna do what we have. I'm gonna invite some of you. I've already got one person on stage with us. I'm gonna invite some others on stage. If you want to come onto the stage, just click the join stage. If your camera and mic is off, you won't be seen or heard by delegates, you just need to turn on your mic and you can answer questions, ask questions. It's open mic season here on the stage and, and who s will just deal with whatever we throw at him. So if you don't wanna come onto the stage. That's absolutely fine. We still want you to use the chat. So pop up your questions in the chat. Uh, all your answers in the chat and who Sam will juggle both on, on stage and chat with us. Um, firstly, I'm gonna introduce, er, George. He's gonna tell us where he's from and then we're gonna pass you over to Sam. So George, where are you from? Yeah, thank you. So, um I'm from uh Syria. I'm currently a senior year medical student in Tin University uh in Latakia City uh for uh the students from the UK. I'm technically an fy one right now. Uh S and uh currently I'm uh preparing for my national exam uh in uh September uh which is like a board exam for all doctors in Syria. We, we need to pass until uh so we can go into specialty. Wonderful. That is brilliant. So George is on the stage. Uh He's gonna answer some questions uh er or ask some questions, but we would love to invite some more. So, like I said, I'm gonna basically go down the people tab and invite you to stage if you want to come click on join and you can come on to the stage if not just pop your questions and answers in the chat. Now I'm gonna hand you over to Husam. It's over to you Husam. Thank you, sir. Thank you for joining us and good luck to your exam. Uh, hi, everyone. Uh, it has been a while since the last time and, uh, there was a lot going on and, yeah, it's a good thing that we are back and hopefully it will be on a regular basis. Happy New Year, by the way, although January is almost over. So, uh, we're gonna continue our talk on heart failure and, uh, and the, and the previous three sessions we covered all the basic stuff about the heart and the pelvic cycle and everything that will, that should help us with understanding heart failure, pathology and uh and management. And then uh last time we talked about the both of the heart failure, which is very, very, very important to know. OK. And, and remember, and then we just previously started to talk about the clinical features of heart failure. So, and we talked about the differences between uh acute and chronic heart failure presentations and usually acute heart failure usually takes days, two weeks to present. And usually it's very progressive in a very short uh period of time and chronic heart failure usually uh continue for, for month years with the patients. And also we talked about the causes and we said we mentioned the three most common causes of heart failure. Do you remember your, what are the three most common kind of heart failure worldwide? Um What I remember from like two years ago, I think uh cardiac infarction um uh maybe uh valve, uh failures like aortic valve, uh like acute aortic valve failure or stenosis and maybe a acute mitral valve failure. Ok. You, you're doing good. You remember uh let's say ischemic heart diseases, ischemic heart disease, not just myocardial infarction. Ok. Even chronic ischemic heart disease can lead to heart failure without myocardial infarction. Also valvular heart diseases in general valvular heart diseases, including uh vulva stenosis and valvular regurgitation. And also hypertensive heart disease is one of the most important causes of heart failure, hypertensive heart diseases. And there are many, many, many causes of heart failure, of course. And we talked about the presentation and most common presentation of heart failure is the shortness of breath, uh volume and symptoms and signs of volume overlooked. Ok. And that would reflect on the presentation in there some symptoms and also in terms of signs, when you find the the pulmonary edema, the lower limb edema, the ascites the liver congestion and so on. Ok. Anyone from the chart or anyone who wants to go to talk to me a little bit about the complications of heart failure, any complication of heart failure, any acute or chronic complication of heart failure? Do you can talk if you want? Um For me, I remember like uh pul like you just said, pulmonary edema uh is one of like uh the most uh common ones I think uh especially for right uh ventricle heart failure, right heart failure. Mhm. Ok. Usually it's a presentation. But ok, what else are you people on the child? Are you able to help me? I think they're too scared. Sam. I think they're scared to pop anything in, in case we drag them onto the, I can just talk and move on. But no, I want to hear of everyone. What they, what do they think? Yeah, Sam will not move on until you put some answers in that chat. So come on. Yeah, this session I could cover in one session but no, I took four sessions and most likely more so that we take our time to um practice maybe uh renal failure, renal failure. Yeah, renal failure. And how do you think renal failure will occur in context of um not enough blood coming to the uh kidneys? I guess like it's just like uh res per because uh the the heart isn't pumping enough. Perfect. Your heart failure has a heart inability of the heart to pump blood in the blood is a systemic circulation, including the kidneys and kidneys are very sensitive to ischemia. So in uh not enough BP, the renal uh system could lead to acute kidney injury and also could lead to chronic kidney injury. Of course renal failure. And what about the potassium? Uh I mean, uh renal failure equals so many electrolyte disturbances like uh we might have uh hypokalemia. Uh mhm and maybe uh hyponatremia, I guess because it's not retrieving. Uh it's not retrieving the sodium from the urine. Ok. What else people are you able to hear me? Maybe they cannot hit me soon. I don't, I'm not sure. Let's ask people. Could you pop in the chat if you can hear and see who Sam and George just say yes, we're here or something. Maybe because it has been a while. They forgot, they forgot me completely. No, they're just scared. No, because he said how the things were. Ok. OK. Thank you. Thank you. Yeah, the, the question is about the complications of heart failure. Uh George uh pointed out some of the complications like renal failure, like hypokalaemia, like hyponatremia. What else do you think? It's, it's written you can, you can, you can look at it as a slide. What are the complications of heart failure? There are numerous complications. We just wanna mention some of them renal failure could occur in the context of decreased renal perfusion and also the cause of some drugs uh that used to, to manage heart failure. Ok. Recurrent infections. Why recurrent infections could occur in the context of heart failure? Peripheral uh peripherine? Oh yes, of course. Ok. So with the heart failure, but it's usually uh a presentation of the heart failure itself. Recurrent infections can precipitate acute heart failure. For example, in patients with, with this chronic heart failure, it can, if you remember the kidney compensated and compensated heart failure, infections can lead to decompensation. A kidney compensation. That's why in patients with heart failure, usually you need to, to, to give them vaccinations to most common infections like influenza. For example, a scientist is also presentation cardiac arrest and sudden cardiac death. One of the one of the complications of heart failure, um respiratory system, what about respiratory system? It, adrenal failure, hypokalaemia can occur as a context of heart failure. Do you take could be due to drug uh side effects like diuretics could be also due to decreased renal perfusion? Ok. Hyperkalemia can also occur with heart failure with heart failure. Ok. Usually it's secondary to to potassium sparing diuretics. Ok. Yes, spironolactone, I think, yeah, hyponatremia can occur in heart failure and this is very important hyponatremia. Anybody knows why hyponatremia is very important. George now. Um because uh like I'm thinking through volumes, maybe losing a lot of volume. Mhm. Anybody know? Yeah, binazine is very important and any patient's heart failure you need to, you need to uh you need to request sodium hypernatremia. Actually, there is a good prognostic feature in patients with heart failure. That's why it's very important to, to, to point it out. Ok. It usually indicates advanced or severe heart failure uh and poor prognostic feature as well as hypertension, for example. Ok. Liver injury kind of carries heart failure due to usually it's secondary to liver congestion, liver congestion and acute, it can lead to just press in liver enzymes or acute hepatitis, but chronically can lead to cardiac cirrhosis. Cardiac cirrhosis is one of the rare causes of cirrhosis in patients who have advanced heart failure, that can lead to chronic congestion in the liver that can lead to cardiac cirrhosis. Ok, pulmonary edema. But at the end, pulmonary acute, special, acute pulmonary edema is usually like uh a presentation of heart failure, but it could be considered as a complication here. Thromboembolism. Thromboembolism is very important because heart failure is um with heart failure, you have stagnant blood, stagnant blood, the heart doesn't pump blood and doesn't move it into circulation well, so that can lead to thrombus formation and embolic phenomena. Ok. Thromboembolism. It's very important and also this sometimes could be challenging because with the liver failure secondary to heart failure, ok. Liver can decrease the formation of some of the coagulation factors and management of thromboembolic phenomena. In these patients with anticoagulant could be challenging. Uh arrhythmias like arrhythmias, sometimes arrhythmias all kind of care and it complicate the management of heart failure. But it is the most common arrhythmia in heart failure patients. Your what is the most common arrhythmia in patients with heart training? I'm not sure. But like I'm thinking about like the most common in general, maybe uh atrial fibrillation. But like I think if it, it means death, I think a ventricle fibrillation, ventricular fibrillation is we are we are afraid the most often is the fibrillation dangerous. But like I think the most common is atrial fibrillation. Most common is atrial fibrillation and very important to, to identify as well. Very uh atrial fibrillation is the most common cause of uh the most common arrhythmia associated with heart failure, sometimes tachycardia by itself. And severe bradycardia can lead to heart failure. And also heart failure could be complicated by arrhythmias, tachy arrhythmia and as well. So you, you know, you need to know which one it started with the process and of course sudden cardiac this kind of care, uh heart failure. Ok. So the uh these are some of the complications of heart failure. We need to identify it. We need to look for it. Ok? Because for some patients, they need more aggressive treatment. And if you are going to talk about the depression diagnosis, heart failure, um it's so this is quite a lot, but we can mention usually heart failure is a presentation of shortness of breath dysnea and or volume overload. So just we need to consider differential of this. At least, for example, the pulmonary causes of uh dyspnea, uh systemic causes of DYN as well as we consider the volume overload. Usually the three most important organs with volume overload is the heart, the kidneys and the liver. At least we need to consider these factors could be associated with each other or each one can lead to the other one as well. Ok. Any question um can you just like uh briefly explain how cardiac cirrhosis happened? Like how can the cardiac card cause cirrhosis? Yup. Ok. With uh heart, there is congestion. Usually the heart failure could be from the left side or from the right side. Either way, usually there is congestion of the systemic circulation leading to the liver. So with the chronic congestion to the liver that can lead to chronic inflammation in the liver and usually chronic inflammation in the liver can lead to cirrhosis. So it's how cardiac cirrhosis can occur. The pathology is more complicated than that. But for the sake of time, uh this is what happened. Chronic congestion of the liver leads to cardiac cirrhosis. And this is it's not common cause of cirrhosis, but it's it could occur in the context of heart failure, chronic heart failure. Is that other question? Ok. Any other question? No, thanks. OK. Anyone want to jump on the stage or shoot a question on the chart? Feel free, please. So this is what we, we were talking about the presentation of heart failure, pulmonary edema. It is very important to identify clinically and cardiologically. OK. Uh Re uh cardiomegaly usually with uh with chronic heart failure and pleural effusion, spitting edema and so on. And the classic uh the classic uh classification of heart failure to the right and left heart failure. We talked about this last time which says there there are many ways to classify heart failure. Ok. It's very important. Uh This is slide because we for heart failure. It's not just the symptomatic heart failure. The process of heart failure usually starts way back before the development of the symptoms of heart failure. Usually thi this stage is I not an early stage. So that's why we need to identify people at risk of developing heart failure is very important. At least we could delay the presentation and decrease the severity of heart failure when it develops. At least. Uh for example, patients who is uh hypertension patients with diabetes, patient with obesity, these patients and other patients who are taking drugs that could affect the heart. These patients, we should identify early and we should intervene. Ok. We should manage the hypertension, we should manage the diabetes. We should de advise the patient to decrease your weight and so on. Ok. So that's why patients at risk of heart failure should identify early and they might need close monitoring and close management. So these patients who have risk factors for development of heart failure, but they don't have any disease affecting the heart. This is stage A in stage B. This is just a stage before development of the heart failure. These are the patients who have have no symptoms or signs of heart failure but have a disease going on on the heart. Like for example, structural heart disease, cardiomyopathy, ischemic heart disease, any structural heart disease or evidence of increased feeling pressures, usually identified with echo of increased feeling pressures. Ok. So it could be identified clinically but usually with echo or some sort of imaging. Ok. Or patients who have elevated cardiac enzymes without any diagnosis. For example, some patients have elevated troponin, but they are not, it's not secondary to ischemic heart disease. So these patients could be at risk of developing heart failure. This is pre heart failure patients. And we need to also to intervene at least to delay or to prevent if it's possible if it's applicable. Then these patients usually at the end develop heart failure. Unfortunately, in in many countries, patients just present as cystic, most of the patients present as cystic asymptomatic heart failure. It and these are the patients who have at least one presentation of heart failure. One presentation of heart failure could be acute could be chronic. Ok? And it's why we give the drugs of heart failure and also we could uh we try other interventions. And unfortunately, most of these patients progress to the advanced heart failure, which patients have heart failure in daily life, affecting their quality of life and you with, with recurrent hospitalizations despite the aggressive management. Ok. So these are, this is very important. I don't think that you're gonna ask uh in your colleague ears, but for clinical point of view, you should be aware of this because if you identify patients here, you could help the patients, you could prolong their lives or at least improve their quality of life. Ok. Any question here um if uh can we like if a child is born with a structural defect in the heart, can we uh do we count them as like stage B or something? Uh It depends on the structural structural disease but in generally, yes, generally, uh some structural disease just need monitoring and the result by themselves. For example, most of uh aor defects, for example, some need intervention early on. So either usually with surgery but a few of them you just need to treat because from the start or from early on, uh the child could have heart failure from early on. So you that's why it's very important uh in in for pediatric colleagues to do complete neat examination and do uh frequent examinations for the child to identify as early as possible. I think generally. Yes, another question. OK. One of the most important ways to uh classify heart failure is based on ejection fraction. What is ejection fraction? What is the injection fr um it's the percentage of uh the volume uh that the heart uh pushes out uh during systole? Ok. The amount of blood that ejected by the ventricles and from the cat. How do we calculate ejection fraction? Anyone can jump in or can using ultrasound? No uh from a physiological point of view. How do we calculate addiction traction? Uh You mean like the formula for it or like? Yeah, but I but I meet people from the Jack. OK. Yeah. How do you clear the ejection fraction? Both? Yeah, olia and there do you agree your uh yeah, it's uh the percentage between stroke volume and uh and uh diastolic volume. Ok. And what is the normal ejection fraction in normal patients? It is a normal ejection fraction? 55 or do you think you are uh 55% or above 55% or above? Ok. So how do we classify heart failure based on addiction fracture? How do you classify in as George said we do ultrasound or we do echo that's called the ultrasound. So how do you classify patient who suspect heart failure? He sends a patient for the cardiologist. The cardio thing to do is doing echocardiography and cause heart failure depending on the ejection fraction. How do we do that? Usually what we know that patients heart failure has reduced ejection fraction, right? That's what we know in general has reduced ejection fraction. Usually the it's usually in general, it's secondary to systolic dysfunction is a candidate to systolic dysfunction. These patients has heart failure with reduced Egyptian fraction is reduced or impaired Egyptian fraction. It is when you find Egyptian fraction, less than 40% less than 40%. OK. There are a subset of patients w in which there is symptoms and signs of heart failure. But when you me, you measure the ejection fraction, you find it at least 50% or more. It's 50% or more this we call heart failure is preserved, ejection fraction was preserved ejection fraction. This is very important why? Because most of the studies were conducted in patients with heart failure to reduce ejection fraction. So it's advancing management of heart failure. Usually it's for heart failure, reduced ejection fraction. And this is challenging and this constitute around 50% of patients with heart failure. So this is very important to remember, heart failure, preserved ejection fraction. And there are some patients in between. We're gonna talk, talk about them in the next slide. So for now, I want you to remember there is heart failure is a reduced ejection fractions. That is 40% or less your heart failure is preserved fraction. That's 50% or more. OK? We talked about the mechanisms of development of both things ECI. So again, this is initial classification. So patients came with symptoms of heart failure, you stabilize the patients and then you measure the e fraction you find in one patient you find ejection fraction at 40% or less 30 something 20 something. So it's heart failure with reduced ejection fraction. In other subset of patients, you find uh heart ejection fraction, 50% or more that heart failure with preserved ejection fraction. So there is some patients in between. As a patient, you find the third patient, you find these ejection fracture, for example, 45 it's more than 40% but less than 50%. So you cannot classify this patient with heart failure with reduced ejection fraction or is preserved ejection fraction. It's in between. You don't know. Is this patient from here? Came to here or from here came to here. So is this heart failure with mildly reduced ejection fracture or moderately reduced ejection fracture? Ok. Fracture. This patient could end up with this scro or with the SC group? Ok. Do you see my mouth because I had, I don't see you because do you see my mouse? No, no. Oh, sorry, sorry. So this patient is heart failure is uh mo fracture can end up with patients with reduced ejection fracture or preserved ejection fraction. This initial classification. So after that, usually there are interventions conducted like you give patients drugs, you could do some interventions to manage the heart failure. And after that, you can reclassify. You don't need to know uh all these details about these classifications at least. Remember these three classifications, heart failure is reduced, ejection fraction, heart failure is mildly or moderately reduced ejection fraction, heart failure is preserved, ejection fraction. OK? Any questions? This is maybe the most important classification from clinical point of view. Any question? Yeah, maybe you forgot. But I always ask if there is no question if it's clear or clear at least. So I can be assured if there is any question you're free to ask. Is it clear? Yes, clear. Yeah, for others, sometimes it could be challenging. So that's why I want to make Sure it's clear. Ok. Thank you. C OK. So we talked about we all know the classification of right and left and by the trigger heart failure and systolic and diastolic dysfunctions. And now we talked about the heart failure classification depending on the ejection fraction. Ok. There's also a functional classification. Very important for the quality of life of the patients. Ok? For every patient, at least you need to classify depending on the ejection fraction and the knee heart classification, New York Heart association function classification, knee classification. OK? And it has four classes. Some patients usually there is no limitation during physical activities. These patients with what we call patients with acute or patients with uh sorry, with chronic compensated heart failure. So they have heart failure but it's compensated very well. And this usually very early on the disease process and they need uh maybe monitoring may be just uh not, not very aggressive intervention. So then other subset of patients, class two have a slight limitation of physical activity. For example, when they walk fast or when they uh climb the stairs, they can have some limitations. OK? X class three. These patients who have marked limitation of physical activity, marked limitation, even uh normal paced walking or uh uh physical activity like it at home or so can lead to development of the symptoms. And then class four of these patients who have symptoms, even at rest, even at rest or even during sleep. Can have these symptoms. And this class for classification in general, the more advanced the classification is the more aggressive treatment is that you need to give the patient. Ok. So this is very important as well. OK. So ejection fraction and knee classification, if there are two things to remember from the clinical features of the patient, because you want to stabilize the patient and immediately to put the patient on either which category of the ejection fraction, which category of knee have classification? Ok. Do we agree? Yeah. OK. Any question maybe from the previous sessions or even from the clinical features and the cause of the case of heart failure or is it all clear? Is it clear for you people? Uh you are looking for the weekend. Uh You are waiting for the weekend. Yeah, I know. OK, so let's go for how to diagnose heart failure. So if we understand what we talked about today and the other day, thanks you again the other days. OK. So the talk from now on will be easier to see. So thank you Rana. Um let's talk. I want if it's possible for one of the people on the chart to to walk me through, if patient presented with symptoms, that could indicate heart failure, what are you going to do in terms of diagnosis? Let's forget about the information, the drugs that you are going to give the patient just diagnose. What would be the you, you can start um uh with acute heart failure, you're asking or any other idea if I presented to you? I have shortness of breath. Ok. So, uh first of all, a full uh history because like we can uh um indicate some reasons for uh the heart failure from the history, like uh the previous uh previous ischemia. Uh then we can go for a clinical examination. Ok. What, what are the important things to ask on the history, uh, uh, any previous, uh, history of, uh, uh, infarctions? Uh, heart disease, um, fam uh, family history of uh, uh, family history of um, art artois. And uh. Ok. Ok. Uh, people from the yard are helping you. Uh, someone said medical history past medical history. Ok. What else help you? He's alone here. Diabetes, hypertension, hypercholesteremia. Ok. Drug history. What type of drugs? I just, I need the most common ones. Ok. Other drugs that are used very common in general population and could, uh, could, uh, cause a bad heart failure or could even worsen the outcomes in heart failure patients? Mm. That's a tough one. Mm. No ace inhibitors. In, in most of the cases it's, it improves uh, morbidity and mortality in heart failure patients. The drugs can be even off label nitrate the pharmacy and buy it. Huh? Uh, I'm thinking about nitrates. Mm. No nitrates. One of those improve mortality, congratulation. No, not paracetamol. Medrol can be used for the same indication as paracetamol. Oh, analgesia. Um, yes. Nonsteroidal, nonsteroidal. Yeah. Yeah. Nonsteroidal. Very important, very important steroidal painkillers or analgesics. Mhm. Like Ibuprofen, like Diclofenac or no steroid in general. No, no, I am asking the drugs that could exacerbate or could precipitate heart failure. Mhm. Yeah. So, a history. What else? Uh, we talked all about the, like the vas, uh, the, the heart, the heart risk, uh, to, like, uh, hypercholesterol and, uh, and any family history, family history. Yeah. Uh what uh you took is a full history. After that uh we can go for a clinical exam which seizure drugs map it for the heart breath. Mm Maybe you are asking because it contains sodium but I'm not, I'm like, I'm not sure right now if it has something to do with the heart failure, but I can check that for you. So, George, yeah. Uh now for a clinical examination um uh first of all, we can uh like after we uh uh assess the patient generally, maybe he can uh come in acute heart failure. So mhm uh uh we can like if uh it's not that acute, not that uh it could help. We can go for like a clinic examination uh check the uh like if we can maybe uh here the time. OK. So we can, we can maybe uh uh hear a uh uh like maybe in a valvular disorder. OK. OK. Good, good. Very good. What are the signs that you look? For in heart failure, patients. Ok. That could be for right heart failure. We can see like a, a uh jugular vein hypertension, venous distension. What else people, other people, please? Ok. Yup. Let, let's let your rest for a while. Help me guys. Anyone can jump just for a few minutes or continue the problem. Yes, we need to, to, to, to hear from you of the shortness of breath. His shortness of breath is a symptom or a sign is shortness of breath is a symptom or a sign. It's a symptom. But you could say the kidney for example, or signs of respiratory distress. Ok. Which the kidney, which, which is one of them. So that could, could, that's the sign. Ok. Y you look for peripheral edema, fatigue. Mhm. Ok. What else? Let's jump to cardiac auscultation if you auscultate the heart. Yeah, I just said that we can maybe uh hear uh some uh like maybe a S3 S four. I mean, and maybe we can actually uh yeah. Can we say patient lying on our position as a sign? Yep, you can, you can, if the patient is be because you need to, with each examination, you need to comment on the general status of the patient. If the patient looks the kidney and doesn't look at the kidney is the fatigue now and also the position of the patient. And if the patient is walking, you need to comment on the gait as well, it's usually more with a neurological examination but me, you can find me crack house. Can fly for that. Yeah. Ok. Very good. So, you took the exam of history? You did the p impressive physical examination? Yeah. Yeah. Skin, yeah. Good. But usually t skin away with maybe with severe shock. So, you did the, uh, my, I can't hear anything. What about other people? Is it clear? Is the voice, my voice clear. Uh Yeah, I can hear you well. Um OK. Uh maybe it's from your side. So uh you did your, you took comprehensive history, you did the impressive examination. So what's next from diagnostic point of view? Just from diagnostic workup, full workup, including the management plan we're going to discuss later on just from diagnostic point of view. Uh The echocardiogram. Now we can maybe move on an echo. Um You do an echo, you need a specialized person, a trained person to do echo. So it's not usually, yeah, you call, you call for echo. But before that, uh ECG maybe labs E CG. Why ECG is very important to do that? Uh because like arrhythmia may may cause the um heart failure. It could point to the cause of the heart failure, it could point to the complications of heart failure. So it's very important although it could be completely normal, but it's very important. Mhm What else? Vital signs? Thank you. Thank you. Vital signs are very important. The T disease is done and in the triage? Mhm E CG. Just touchable ultrasound echo. What else? It is simple as an ac than is an echo. Good chest x-ray. Yep, chest X ray. What are you looking for in chest X ray? Patients, heart uh maybe cardiomegaly, cardiomegaly. What else? Mm. Uh Pulmonary edema. Signs of primary edema. What are the signs of primary edema? Uh fluid that could be also pleural effusion? So what are the signs of pulmonary consultation? Maybe uh bilateral? Mhm What else? Blood tests also are very important currently? Lines. Yeah. What are currently BS carried by you? Not? I what are cars? Ok. Uh We said blood tests, blood blood tests uh CBC mainly because like uh anemia can accelerate the heart failure. CBC. What did he say your uh anemia can extubate the heart failure? Yeah. Yeah, of course, you need to do CBC. What else? Yup. People. Thank you. So, regarding blood test, CBC, what else biomarker is very important if you are going to, to order two biomarkers, what are they urea electrolytes? Yeah. But if you are going to order two by Mark Troponin and C MB P MPM. BBM PPM B MP. OK. Uh beta A peptide. Yeah. MB. Why B MP is important? We can all understand is important but why B MP is important? Why it's important? Sometimes it's uh oh sorry most of the times it's very, very helpful diagnosis of heart failure. Although high BMD is not enough for diagnosing heart failure, not, not, not prognostic. I, I'm not sure if it's prognostic micro but in the context of diagnosis, although high BMD is not sufficient for diagnosing heart failure and low BMD is not sufficient to exclude heart failure. But also it's very important again. Ok, let's see. We'll see. So any patients with heart failure, like most patients or all patients, we need to do to history and examination. It depends on the presentation. If his presentation is acute, of course, we need to just do focus history, focus examination, stabilize the patient. And later on, we're gonna conduct a full workup. But if it's patient is stable from start, just has symptoms going for a while, we need to do full history, full examination, full history, starting from you all jumped to past medical history. Remember to take full history of the current condition right now, history of presenting illness, take it by details. You should know to what uh when did it start to? What degree does it affect the patient? And if there is any complications out of it that you can identify by the history and also in the history, it's very important to try to ask about the cause of heart failure because in a heart failure, remember your goals, you have three goals is the workup to diagnosed the heart failure, including the classification of the heart failure. To try to identify the cause of heart failure. Because if you identify the cause early on, you might be able to reserve reverse or to help the patient life better. Ok. And the third to point out any complication of heart failure. So you have three goals and this go starts from the history and examination. So from the history you take history of presenting illness, it could be ischemic heart disease that lead to heart failure. So you ask, do you, do you have chest pain, pain a year for, for uh for three years, I have chest pains that comes like uh uh when I jog in the morning and uh it uh when I rest and the patient might be not, not all patients would mention that to you. So you need to ask about it. Maybe it's atypical angina. Also you need to ask about that, maybe it's hypertension. Uh You need to ask if you measure your BP and so on and if there's any complications of heart hypertension and other symptoms, maybe diabetes. So you need to ask maybe smoking, you need to ask about all of these things. Ok? And then you go to the past medical history, maybe there history for hospital admissions due to heart failure or other persistence of heart failure. Uh Some uh you need to ask about recent surgeries that could lead for example, to ischemic heart disease and that could lead to heart and so on. So you need to ask about the full history, including the medications. Uh many medications could, could affect the heart, including nonsteroidals. Uh You need to ask about the family history, about the social history and so full history. If you have, if you are in a suitable situation, and then you do complete physical examination, including the cardiovascular examination, usual cardiovascular examination, you need to start by the pulse by the pulse from the pulse. You could uh could point to you, for example, irregular irregular region that could be atrial fibrillation. All right, could point to low volume above or high volume above. So from the from the above, you, you gonna start to think about the heart failure and the cause of the heart failure itself. Since the no uh examination of the precordium including the cult, very important for additional heart sounds for any murmurs that could be a cause of heart failure. And then you conduct a full uh examination, looking for signs of volume overload and so on. So for history, for examination and then investigations, there are some investigations that you are going to order for all patients like CBC, like electrolytes like uh cardiac biomarkers, ok? Uh like uh renal functions, liver functions. And there are some investigations that you're going to order according to what you suspect to what you suspect. Ok. Uh radiological, all patients with heart failure should have just x-ray should have just x-ray. Ok? All patients with heart should have chest X ray, chest X ray is very important. Could I could be completely normal, that doesn't exclude heart failure, but usually it's abnormal. Uh It could point to as a pulmonary edema could point to, for example, effusion associated with heart failure. It could point out to you uh other causes. Maybe you suspect heart failure, but it's not heart failure, it's pulmonary condition. So that's why it's very important to and uh ask for radiology, a chest X ray. Also, for the, of course, we need to do ECG ecg could be normal, could indicate the cause or could indicate some complications like arrhythmias. Ok. And then for all patients, of course, you need to do echo but sometimes it in some settings, echo is not a goodly available. So that might, you might need to refer the patient or to wait for a while. And then some patients could undergo invasive invasive uh diagnostic tests as well including uh uh uh monitoring, uh including um uh other imaging including cardiac biopsy in some cases. Ok. So this for all patients, you're going to do all the blood tests, ECG and X ray and echo and then other investigations as required. Let's not forget from the echo. We're gonna know if the patient has heart failure is reduced, improved or mildly reduced ejection fraction. And then we need to identify the classification of the patients. Class 123 or four because a also that one will affect the management plan of the patient. OK. So from the lab, CBC renal function, electrolytes, thyroid functions in general. It's, it's uh it's advisable, es especially if the patient has something to, to point out the thyroid disorders, but it's advisable and you have to order at least TSH, TSH. OK. And PM PPM P is very important because it has high negative predictive value, high negative predictive value. It's especially important when you are not sure if the dyspnea is secondary to heart failure or other causes, it including pulmonary causes. So if it's high B and B is high, this is supportive of heart failure as a cause of dysnea. Ok. So that's why it's very important. It has high negative predictive value. If you don't know what is a negative predictive value, you need to read about it negative and positive predictive values. Ok. So in general, for all patients with heart failure, usually other PM PPM P. OK. Then chest X ray, you're gonna look for lung vascularity. Usually it's increased, we'll, we'll see one example in a minute. Usually it's increased, decreased lung vascularity and you see the pulmonary edema, you could see the pus and it could point to you as a cause. For example, it's heart failure secondary to pulmonary condition, you could see signs of, of interstitial lung disease or obstructive lung disease or so on. Ok. Then all patients for ECG and echo for ECG, you can see signs of uh cardiac enlargement and so on. This echo is very important to look for ejection fraction, maybe some causes like uh vulval or heart disease. And since there are other investigations as required, I'm not going to go through them. So you will not be confused right now. Uh So let's see the X ray, I'm not sure if it's quite visible. Uh but you see always you see the prominence of the blood vessels from usually this is with chronic heart failure. So it can lead to pulmonary hy uh pulmonary vascular hypertrophy and pulmonary hypertension. So it will be prominent. Ok. Usually also hilar vessels from pulmonary hypertension. You see that the shadowing of the ov edema usually runs between the septic, between the two septic. OK. And also septal or B both of them in the fluids between the septal. OK. Fluids in the septa. And don't forget to look for the costophrenic angle to, to see if there is pleural effusion or not. OK. And then cardiomegaly in most patients with heart failure, you can find cardiomegaly in some patients, you can find normal heart or even small heart that depending on the cause. So any question here so far, uh yes doctor uh the BMP test. Uh what does it exactly provide us about the cause? I just didn't get the idea of the causing the causal of the heart failure. It, it carries a high negative predictive value, negative predictive value means in the presence of a negative test. OK. Uh usually if it's negative, this mean very unlikely to be heart failure, ok. Very unlikely to be heart failure. But you cannot just look at B and B alone and say this is heart failure or this is not heart failure, you look at the whole picture causing the history examination and other tests. But sometimes it's very difficult to, to, to, to know if the same cause of the, if the presentation is due to heart failure or due to other cause like pulmonary cause or systemic causes. So you order BMP if it's high, this is very likely to be heart failure. But most important if it's negative, this is very unlikely to be heart failure. Ok. So it's by by itself looking at B and B alone is not helpful, but in the context of the presentation, it's quite helpful. So it like uh just serves in the, the goal of uh like getting the idea of there's a heart failure, like it's more on the negative side of heart failure. Yeah, it's more of the negative side. So if it's high, this also would be uh BMP is raising heart failure because it's sec it's, it's secreted from the secreted from the ventricles and A to promote uresis. OK. That's why P MPM B and are are increase in heart failure and other causes as well even in some noncardiac conditions, PNB could be high. OK? But in general, usually in patients with heart failure. Is high. Usually in general stretching of the ventricles from the volume overload, usually release of AP and P MB to promote uresis. So that would lead to diuresis. So that could uh decrease the preload and afterward of the ventricles. OK. Another question George is, is it clear George? No, nothing. Thank you. Uh huh. Any question. How many pill do you have today? 18. OK. OK. So let's wrap up as things get a slide. Yeah, of course. Um send it to so every time I just forget to send it. So uh this if patient suspect is heart failure, you need the clinical assessment at first clinical assessment xray examination and depending on the context, uh yes, the stretching of the ventricles and atria can lead to increased PMP and AP. OK. So if patients we suspect patient to heart failure, we need to clinic cholesterol physical examination, depending on the urgency could be focused, could be comprehensive. Then for all patients ecg some labs and chest x-ray. OK. And chest X ray then in many, in many situations, we're gonna order P MP at least uh arthritic peptide, of course. And then we're gonna ask for echocardiography and if it's necessary other test as well. So when we reach here, we should at least know what type of heart failure do we have been uh looking to the ejection fraction and looking to the knee classification? So with the confirm our diagnosis. So is it heart failure is reduced ejection fraction, heart failure, preserved ejection fraction or is it heart failure m reduced ejection fraction. OK. And we should of course, look for the any pre factors, any cause and initiate treatment immediately because early management could lead to better outcomes, could be, could lead to better outcomes. And we are going to know why it's very important to classify, classify patients depending on the fraction next time when we talk about the management. OK. So any question, if you don't have any question, let me know uh how do you feel about the decision? If anything is not clear, you need me to, to go through it in more details next time. OK. Just let me know. There's a chat, please. Your what do you think? Uh it was great. Thank you. I mean you went to get rough on me with the questions like thank you in uh you went to get off of the questions but like thank you. Yeah, because you said two years without uh cardiology. So I II needed to to push you. So you're going to review cardiology. Yeah, I'm I'm currently like reviewing it. That's why. Uh Yeah, that's why I like. Thank you for the question. It's very useful. No, thank you for your participation. Really. At least I am not, it was not all the only one who was speaking. OK. So what do you think any question if it's, do you think cessation is good? Yeah, these interactive sessions are really like useful. Um OK. If I am uh pronouncing the name, correct. Yup. It's very important because it affects the management as we are going to see. Next time I want to talk in a lot of details about the management about different drugs used in heart failure. And we'll see why it's very important to identify the ejection fraction of the patient. Mhm. What are the immediate actions? That's a good question. And then we'll leave that as a homework for you all because next time we're going to talk about it, uh You hope next or week or the week after the next week in, within two weeks you're going to have several session. I will try my best to for these decisions to be a caregiver. Mm uh This is like um kind of uh uh summarize what we talked about in this session. OK. So, um you can take a screenshot until you, you have the slides if you want. OK. So I think there is, there are no more questions and they don't want to tell me about their opinion about the decision. So it's up to you. Mhm. Has nobody got any opinions? Come on, put them in the chat. What didn't you like about who Sam's teaching? I think George might uh might say it was a fact that he got asked really awkward questions that he maybe didn't know the answer to. Yeah, I feel embarrassed like that. I'm technically is, is about to, it's about to graduate as I understand. So it's very important all of this. Yeah, like nine months I'll be graduating. Yeah. Yeah. I'm gonna be ready for these questions. If it has been three years since I was reviewing cardiology are very good. Yeah. Two years. Yeah. Uh especially with the COVID lockdown. It was really rough. Yeah. Yy, you don't worry, just, you need a little bit of revision and everything will be fine. Perfect. Thank you. Yeah, thank you. Is there any other questions anyone? Um is there anything um So to the delegates, is there anything that you would like to cover that Hussam hasn't covered. Is there anything sort of on this topic? Not on anything else but on this topic, is there anything else that you think? Actually we haven't covered this over the last four sessions? It'd be really good if we could cover this. Um do pop it in the chat and we'll see if Hussam can er incorporated in a talk going forward. Um Yep, anything get fitted. I am quite open to the feedback. Even if like you think if I modify my teaching method in a way. Uh Don't mind. Just let me know. So, Husam, do you teach on, is it just uh cardiology kind of things that you want to teach on or uh is there anything else that you are passionate about it depending on the? So let's see what, what topics do they want me to cover for that? I love, I really love surgery. I love using my hands. That's why, uh, also cardiology is kind of like using your hands essentially. So it's like the dark side of me, you know, George, uh, the co, the common rule that all doctors start by saying that I'm gonna be a surgeon and then most of them change their opinion. Well, I started, I wanted to be like a, uh, I think I wanted to be a gastroenterologist but now like, uh, in three years later, no surgery. It's only surgery for me or cardiology or interventional radiology. Ok. Nice. Keep your quite often. I, II believe that all people here, most of them are hesitant about what to pursue this feeling. Yeah, like a month, I'm nine months away. I'm still hesitant. I'm afraid like the day of my decision, I'll, I think on the day of my decision I will stay hesitant. I'm just gonna like, randomly choose one. No, no, don't worry. It, it's quite normal. George. Do you have commitment issues? Yeah. II II think I have, I do have because like I love exploring multiple aspects of medicine. That's why I think I can't stick with one, specialty. Yeah. Perfect. Right. We're gonna say, um I'm gonna, if that's us done, we're gonna wrap it up. You should get your feedback form in your inbox. Please fill it out in your feedback form. There will be er, suggested topics that you want to, to um hear about going forward on middle education. Please let us know this middle education is for you. I'm not medical. I don't know what you need and what you want. So please do pop down what it is you want to learn and we'll see if we can get some speakers onto the platform who can facilitate that teaching. Ok. So we really need to know what it is. You want to know as well as what can Hussam teach going forward in 2024. You know, like I said, medical education is for you. Um I'm here to enable you to get further education. So however, I can do that, I will. Um So please let us know after you fill out your feedback form, your certificate will be on your meal profile and you can download that. You can get a summary of all the education that you have had on metal by going to your profile. And Hus's previous three talks can be found. Um If you, you can either search for Husam, you can search for cardiology and you'll find his on demand content on there. OK. Everyone. So I think as long as he's happy, we'll say goodbye to everyone. I just minutes and then you can easily reach me out here on and on uh for any question regarding this topic or any other thing in the field. OK? Yes. So please get Hussam on at Husam underscore five A lo um, and he's very, he's very chatty and I don't know if anyone noticed that, but he's very, very chatty and he loves, I think it's fair to say Susan that you love teaching. I think that's something that I've learned over these past four sessions that you love teaching. And I think when, when people hear others who are passionate about something you can't help but, but tag on to that as well. Yeah, I have a lot of right now. So yeah, that's why you need a maybe I could be one. Perfect. There you go. You heard it here first? Yeah. So we'll say goodbye to all the delegates. OK? So thank you very much and we'll stop going live and we'll say goodbye, take care everyone.