Computer generated transcript

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

Hello everyone. Good morning. Well, it's for me. Anyway, uh Monday morning and welcome to uh part six of H Sam's talk, apologies that we had to postpone um from Saturday uh who somehow to actually cover a colleague at work with all our medical education events. Our speakers are still working and they're giving their time to us freely to offer you education. So um sometimes this does happen, something crops up in the workplace and we have to make changes and we have to just adapt to that. So, apologies, but he's here today and he's ready to chat as always questions in the chat. We may ask invite you to come uh onto stage. It might, you might have something that says, invite um uh invite to stage, come to stage. You can click on that if your mic and CM is off, delegates won't see you, but it just means that you can answer questions a little bit easier. So if you don't want to click on that, that's absolutely fine. You can still put your response in the chat. But I know that Hussam quite likes the interaction, having people on stage with him. So if you have the invite, you can click on it, keep your mic and cm off and then if you want to answer a question, you can just turn on your mic and answer. Ok. Feedback form will come to you at the end of this event in an hour time and once completed, your attendance certificate will be on your medal account. So without further ado I'm gonna pass you over to his and I'm gonna start inviting some of you to the stage. Ok. Thank you, Sam. Uh Thank you, sir. Hello everybody. Good afternoon from here. Uh I have finally reached to our last session on this report and tell the heart failure. Uh So we were planning to have 3 to 4 sessions maximum to, we took our time due to the significance of this topic and finally here. Ok. Uh We're just gonna start immediately last time we spoke about the medications, some of the medications that could be used in patients with heart failure. And we finished our topic regarding the uh with acute heart failure management. Uh OK. Yeah, I saw your questions and uh they are very, very good questions, but some of them are irrelevant to this topic and some of them are very advanced, just feel free to reach me on Twitter and like I'll be happy to discuss these questions with you. Ok? And this time we're going to talk about the congestive heart failure management. OK. Congestive uh uh or chronic heart failure management. OK. And the management of chronic heart failure depends on which stage the patients on. Uh some patients are on very uh uh early stages and some of them are very advanced stages. And of course, which category is the heart failure of this patient is especially depending on the ejection fraction, ejection fraction. And the most important thing, heart failure is not only managed by the cardiologist, it's not only managed by cardiologist. It's, it's like all the medicine. It is multidisciplinary, multidisciplinary team collaboration. What do you think? What team, what, what the team should be consist of like uh which specialist should contribute to management of heart failure? What do you think you have a cardiologist? Of course. Yes, nephrologists are important. Mhm Nephrologists. What else are endocrinologist, person or pulmonologist? Could be important? Pharmacist. I will, I will, I will post my telegram account as well and saying no phar pharmacy pharmacies are very important. Radiologists are important or not. You pee, of course, you pee of course uh family physicians. Of course. What else? There are many difficulties regarding heart failure and heart failure is a chronic condition and many of the chronic conditions could have or absolutely have um have psychosocial issues. So we need psychologists, we need psychiatrists and also you need social workers, social workers. So it's not only work out of the cardiologist, the cardiologist could be on the center of this all of this but we need the collaboration of of uh many specialities. OK. And there are many difficulties regarding management of the heart failure. One of them is that uh there are many, there are many, many drugs that the patient should take. Ok. There are many drugs that patients should take. So there is a concern from the cost from the side effect from the toxicities from drug interactions. And usually patients with heart failure have many comorbidities, many comorbidities as it should be treated along with the heart failure. Some of this could contribute to the heart failure. Some of them could not. Ok. And one of the most important steps in management of the heart failure is that you need to educate the patients, you need to educate the patients. The nature of heart failure is a progressive nature of heart failure, regardless of the management. And um and what to do to decrease the risks for heart failure and to improve the mortality and morbidity in these patients? Ok. And also to implement in every patient with heart failure, you need to implement lifestyle changes, lifestyle changes. What are the advi what is the advice that you are going to give to the patient? Y sometimes cardiothoracic surgeries are important as well. What is the advice uh that are going to deliver to the patient regarding the heart failure? Regarding the lifestyle modifications? First one would be the diet. Um are they making any changes to the diet Yes. What, what uh, what is the dietary modification? Um, in terms of cutting out on the high, um, uh, fat diet, high fat diet and, and diet, low sugar diet are recommended. Mhm. What do you think? He said high fat, low sugar diet? A big thing. Dietary modifications, lifestyle modifications improve heart failure. Then I said fair thing is the diet, low salt diet is very important, low salt diet because these patients are already uh uh clinically overloaded. It's so low salt diet. Ok. Low salt diet. What else regarding the diet, healthy diet that uh consists of all the essential elements, including carbs, including proteins, including uh healthy fats, not just high fat, healthy fat, healthy fat. Ok. Um, we just started, you don't worry, then exercise very important exercise. What type of exercise? I think it can be divided into um, the vigorous exercise. And also, um, it's divided into um moderately a brisk exercise and high risk depending on the individual actually. So we can't exert them, uh, allow them to do quite a lot of um, high, high, highly risk exercise. Mhm. Ok. So I think depending on the patients that we decide the level of exercise. Ok. Is it uh aerobic or anaerobic exercise, aerobic or anaerobic exercise? I think if, um, I would recommend um, anaerobic, actually, aerobic, did you say aerobic or an aerobic aerobic will, um, aerobic will increase the heart rate, isn't it? Both will increase the heart rate, isn't it? Yeah, but better, better aerobic as tolerated, regular exercise, aerobic, as tolerated regular exercise. And then patient can increase, can increase the duration of exercise. For example, if patient can start with five minutes, that's totally fine. That's the base line that we try to build up on that. Uh, just ok, better aerobic, accelerated regular exercise. Ok. Uh then, uh, after you address the lifestyle of the patient, then you need to address the risk factors. As we said, these patients have many risk factors, has many comorbidities including uh yes, cardiac physio therapy is important as well. Uh to address hypertension diabetes to there is any chronic conditions that the patient have and some of these patients end up with depression and many psychological issues and unit issues as well. And also you need, we need to address the cause and sometimes management of the cause in few patients could reverse the symptoms, could reverse the signs. But uh in many patients, we just need to, to, to, to, to delay the progression. That's why we need to address the cause and to prevent the recurrence. Uh For example, if patient with ischemic heart disease, we need to address that cause to prevent occurrence of further ischemia to the patient. So do you remember what are the most important, what are the most common causes of heart failure? I just said one of seven ischemic heart disease like uh probably the most common heart disease like mostly any cardiovascular uh uh disease can lead eventually to heart failure. Yeah. But what are the most common? What are the most? Most is the three commonest causes of heart failure. Stenocardia is one of them, uh hypertension and uh probably hypertension, uh one of the valvular diseases, but I'm not sure about how common they are. Hi. But what did you say you are sorry? Uh valve disease, valvular disease, of course, valve disease, valvular disease, hypertension, ischemic heart disease are the three most common cause of heart failure. But there are many, many causes as we discussed in about the physiology. Um Can you explain the reason considering high fat, low carb diet and preparation for pet scanning? Ok. Uh I have no answer to this question actually. And it's irrelevant. Please please ask questions relevant to the topic. Please. Atherosclerosis is not, it is not a cause by itself. It's just a uh it's a patho pathological changes and the risk of that could lead to, for example, ischemic heart diseases and that could lead to heart failure, but acle is not a clinical diagnosis by itself. Ok. And as we discussed last time, I have many drugs that could be used in man of heart failure, including drugs that act on the on the strong system, beta blockers, uh vasodilators and uh diuretics. And then uh so in cause cotransporter inhibitors, ivabradine diuretics and strong. So let's discuss how we, how we use these drugs to manage heart failure. Can you see this slide? Yes, doctor. Ok. So this philosopher cause heart failure with reduced ejection fraction, heart failure to reduce ejection fraction. So once you establish the diagnosis of heart failure to reduce fracture and you, if the patient is congested, you need to address the congestion, you need to address a congestion. Patient could be accurately congested. And these patients need to be admitted to the hospital and managed most likely by parenteral uh infusion drugs or sometimes needed to be with assisted ventilation or even intubation. And if chronically uh congested, this patient could be treated as outpatient uh in outpatient settings. So in these patients, if they are congested, you need to give diuretics, either low diuretics plus minus CD diuretics. Ok? And then immediately you need to start with the drugs that improve the morbidity and mortality. Uh You need to start with the drugs that, that uh address the renin system is the best is, and this is a receptor uh and, and NLY inhibitor and receptor blocker is lysin inhibitor is other Arab. Ok. This is the best but you could kind of start with Ac inhibitor or Arab if that's unavailable. Ok. We need to start with beta blocker me corticoid receptor antagonist and so cotransporter uh A two inhibitor. Ok. There are two sodium glucose transporter inhibitor used in heart failure with reduced ejection fraction. You can use one of them called dine or in NZ what are the these drugs first uh used was, was uh first were used uh for management of patients with diabetes. But even in patients with heart failure without diabetes, they could be used. Why, why we can use sodium will cause co transporter inhibitors. Although they are hypoglycemic agents, even in patients with uh diabetes, right heart failure fraction, you can use one of these two, these patients. Uh these drugs were found to improve mortality in patients with heart failure. Uh That's why they could be used even in patients. That, that of course, uh if patient is diabetic, you should use them absolutely 100% you should use them. Um They have side effects. Of course, one of them is hypoglycemia but they improve mortality and morbidity. Ok. Do we start these medications simultaneously? At the same time a patient presented today with heart failure and we, ok, we made the diagnosis, we echocardio showed to reduce ejection fraction. You just start the patient at the same time as angiotensin agent, beta blocker, another called aldosterone and sorry, embryo cortico receptor like spironolactone and uh dozine, for example, did it start at the same time? I think it might have a better glycemic control. I think patients is eo glycemic. It's not hypoglycemic or hyperglycemic. So it's a blood deal cause is not uh an issue here. Do we start these medications at the same time? I think it will be mailed to you. So there are other really, there are two schools, one is called that you can start this medication at the same time with low, with lowest possible dose and build up the doses to the desired dose. Ok. Uh The other scores say that you start with one and then uh within few hours to few days, then you can add the other one. For example, you start with uh uh with uh sacri, then you add spironolactone, then you add uh beta blocker in, for like, in, in, in a few days to a few weeks. You, you reach, uh, you, you put the patient on the all medications. Uh, what's the most important thing that if patient presented with acute heart failure, don't just start beta blockers immediately unless the patient is stabilized, unless the patient is stabilized. Ok? Usually within 24 to 48 hours, sometimes even more. So you start with this medication and then you, you monitor, you monitor the patient. Um, if patient ejection fraction improved, OK, then we call this heart failure is mi uh mildly preserved ejection fraction and this patient just be monitored. They, they might need additional medications or not. But if the pain is still ejection fraction is not improved and patient is still symptomatic, then you need to consider another modalities. And one of the drugs that you can consider is, uh, vasodilators that's hydrALAZINE and nitrates, especially in, uh, in African or african-american patients. Ok? And then there are other model that you can consider like implantable cardiac defibrillator or CRT or mechanical support or cardiac transplantation according to the cause according to the, to the patient as uh as well. But the most important thing is that these four medications that is the one of the either Ac or Arabs or RNA, RNA S beta blockers, spironolactone and sodium glucose, cotransporter inhibitor. OK. Any question on this, any question, beta blockers because it say for instance, if it causes bronchospasm. So why are we using in heart failure immediately after using other mo what does the issue is uh bronchospasm in patients with heart failure? If patient is not asthmatic, he's not C OD patient. So what what could be the problem? Uh will it not exacerbate the um breathlessness or dyspnea? Ok. Uh In acute, if patient is unstable patient presented with acute heart failure, we don't start immediately. But while the patient is stable stabilized, after stabilization, we can start with very low dose and build up the dose. There is always a risk of uh conservation of heart failure symptoms as a start of beta blocker medications. That's why patient needed to be monitored closely during when you start beta blockers. Ok. And we usually lean towards the cardioselective beta blockers. Ok. But even with cardioselective beta blockers, there is a risk of uh pulmonary side effects. So some patients will not tolerate beta blockers at all, even if they are not asthmatic or CO PD patients, but most of patients whose heart failure, they tolerate beta blockers very well, very well. And beta blockers, they have their benefits outweigh the risks of uh excess heart failure and other side effects. That's why we use them in heart failure. Did I answer the question? Uh Yes doctor. Thank you. OK. OK. Uh Any other question? OK. So these are the main uh drugs and their benefit. Like this is one of the studies and their benefits. Me corticoid receptor uh antagonist sodium will cause called transporter hydrALAZINE nitrate. And you see that the patients benefit very well from these medications. There is no time to go through these trials but they are very beneficial. Like patients monitor at least for, for one year, some patients monitored for even more and they show improved survival and even dec and improved morbidity as well in these patients. And they compared it to the advanced modalities like uh cardiac crystal cardio therapy and implantable cardiac defibrillators. And in patients with uh with early heart failure symp uh symptoms, they are very beneficial. Ok. Same. And the, and um after uh starting the, by the way, we call, we call these medications, goal directed medical therapy, goal directed medical therapy because our goal in heart failure is to decrease the symptoms that is through diuretics, to improve morbidity and mortality, that's through these different medications. So that's why we call it goal directed medical therapy. Ok. So if you, sometimes you need additional medications. For example, patient is maximum beta blocker or patient beta blocker is heart rate, 70 BPM or more. You need to start Iine, Iine. Ok? And sometimes in some patients you need to start a medication called V that's for advanced heart failure. This patient with uh elevated ND levels or maximum heart failure medications and it reduced ejection fraction as this drug uh is Guana uh uh drug and, and uh and we can use it in patients with heart failure medication. Ok. Uh Zend digoxin. Yeah, I saw your question but I am going to discuss it now. Digox in patients with heart failure with many admissions. Ok. With multiple admissions or patients, heart failure, radiation fraction with atrial fibrillation, we can use digoxin, we can use digoxin. Digoxin improve morbidity only morbidity but many, many, many studies conducted in Digoxin showed that digoxin increased mortality, increased mortality even if it's used for a long time. That's why we need to use digoxin with the lowest possible dose for low for uh for shortest possible duration, shortest possible duration because digoxin has many side effects, has many drug drug interactions, many drug drug interactions and some of these side effects with digoxin could could cause any type of arrhythmia. It could cause pre arrhythmias could cause arrhythmias. That's why you need to be careful with digoxin. Ok. Uh In some patients, we can use uh bone a fatty acids. It showed in some patients, they, they have uh positive effects on mortality and it could be used in selected patients. And if patients has hyperkalemia from renal impairment, from uh cortical etcetera antagonist from angiotensin agents, then you need to give potassium blinders, give potassium blinders. Ok. F Carmi, if iron deficiency, please ask questions related to the topic. Uh doesn't metoprolol have a minor effect on beta two which means it improves pulmonary symptoms, meta metabol and other cardio selective drugs should in theoretical, they are selective beta one antagonist. Ok. But it's not absolute selectivity in some situations, especially if the dose is high. These drugs could have effects on beta two receptors. Beta two receptor antagonist causes bronchoconstriction. That's why it could exaggerate the symptoms of obstructive pulmonary diseases. Ok. Uh I've actually, I II remember that I've read in my pharmacology that the metoprolol has an agonist effect on beta two. Like it activates beta two doesn't uh deactivate it ago. Yeah. No, it, it, it synthesized as selective beta one antagonist, but it could block beta two as well in some situations. Yeah. In high doses, sometimes even in, in some patients on diabetic dose, they can cause broncho constriction. Thank you. Yeah, very good. Gu Yes, the very good. It's really just in selected patients with uh reduced ejection fraction. Ok. And still have elevated uh ty level usually in patients uh who are admitted to the hospital usually and elevated D levels. It's very bad. Yes, very selected patients. It in these patients, it can improve the symptoms, it can improve, improve mortality as well. Ok. Another question. Ok. So this regarding heart failure is it was the ejection fraction which for patients with heart failure is preserved, ejection fraction. Of course, we can use diuretics. If patients has congestive symptoms, then sudden theos co transporter inhibitor are very important. We just use hyzine, dozine doesn't show any improvement as hyzine. It's one of the differences in patients with heart failure is reduced fraction. We can use dine or IMA imaz. But if patients is preserved to use Igli, ok. Ace inhibitors didn't show much improvement in patients with heart failure, preserved ejection fraction. But and the 10 receptor uh blockers, lysin inhibitors show remarkable improvement or Arbs could be used as well. But RNA is, is the best, the best an corticoid receptor antagonist are very good. Also, beta blockers didn't show much improvement as well. Ok. So we use these three drugs. So, umbilical Mra with RNA or if not available or OK. This pains, heart failure with preserved ejection fraction. OK. In patients heart failure mildly reduce ejection fraction. This patients get fraction between more than 40 less than 50. Uh Here all uh Renin inhibitors all are good to be used and beta blockers could be used as well. So you see the differences. If we, if we go back to the fairest in harder ejection fraction, you can use and gas a receptor blocker niacin inhibitors or AC inhibitors or Arbs in addition to beta blockers, corticoid receptor antagonist. And so it will cause cotransporter inhibitor. Ok. But in patients with preserved ejection fraction you use and its receptor blocker ne inhibitors or Arabs. In addition to sub umbilical called transporter inhibitors and no corticoid receptor antagonists. Ok? And in patients moderate reduced ejection fraction, you can use beta blockers. It's, it's very similar for mo fraction, very similar to very similar to the uh, heart surgery is reduced in the fraction. OK. Is it clear? Uh how does uh acerate fatty acid bring about elevation of heart failure symptoms even though it's a fatty acid? Uh, actually, I uh Right. I don't know, actually, I don't know if the mechanism is known or not, but I can, I can look for that. Just uh, drop me uh this question on Twitter or Telegram. I can look for it. OK. Any question, is it clear if no question just send to tell me if it's clear or not. Uh who Sam is um relying on you guys to answer if the question is clear. I am not medical. He has no hope of finding that out from me. So if you could either put a yes in the chat or come on and say yes, if it's clear to you, if it's not clear to you, just say no. All right. Thank you. Yes, please. Because OK, for B side fatty acid as far as I remember, but still not 100% sure they have some effects on uh on uh P MBA B and P MB levels. Ok. They decrease the B MB and that why it could have positive effects on patients heart failure. But how do they decrease PM BI? Don't know. Ok, so let's go. Ok, don't we, we shouldn't forget about other, other uh comorbidities for patient hypertension. we need to address hypertension, we need to address the diabetes. Ok. For sometimes this, the drugs are used for heart failure could address the other symptom. The other condition, for example, sudden glucose cotransporter addresses the hyperglycemic patients with diabetes. Ok. They have also positive effect on kidney bu and they could decrease the risk of nephropathy. Ok. Diabetic nephropathy. Ok. And for patients with coronary artery syndromes, uh ischemic heart disease might need revascularization, ok? And some patients might need anticoagulation, for example, in patients that have atrial fibrillation. And so we just don't forget about other comorbidities. Usually it's many patients have hypertension have diabetes, ok? And we at least we don't forget about this. Uh So, so by this, we reach to the final points we need to address. We, we discussed on this series of sessions because the heart uh and to discuss the cardiac cycle and the E CG and it's the pathophysiology. Has the heart failure, could the care and the causes of heart failure. Then we discuss the clinical picture of the heart failure and the classification, heart failure, especially for knee classification and uh heart failure based on ejection fraction. And then how to diagnose heart failure and how to manage heart failure. Ok. Any question on heart failure? Because I have questions for you. Ask me before I ask you any question from the start? Ok. Then are you ready for the questions? Yeah, I'm considering that because II saw that many, many of you asked for uh A CG digoxin need monitoring, of course, need monitoring uh in all patients. You need to monitor it clinically. In some patients, you need to monitor even his blood levels because digoxin is another therapeutic index medication and it, it's very toxic medication. Yeah, let's hope for that. Ok. I guess you are ready. So let's deal you questions. OK? Anyone can raise the question and try to answer it. Anyone, any volunteers? Ok. I'll read it out. Ok. Thank you. Doctor. This white man is noted to have uh moly severe congestive heart failure with impaired systolic function, which drugs most likely lower his risk of mortality. Uh A angiotensin converting enzyme inhibitors B loop diuretics, C digoxin D aspirin. Um Should I answer? Because I think I know the answer. Uh The answer goes like uh as we before uh Digoxin doesn't only improves morbidity, uh loop and tizide. Uh diuretics don't improve mortality as well. And if I don't know, I don't remember what's the role of aspirin because I don't think we discussed any using of aspirin in heart failure. Ok. So a as would decrease uh mortality, morbidity, loop diuretics have an effect on mor morbidity. I think uh, diuretics and digoxin digoxin improves don't improve. Yes. And digoxin might, might, uh might increase mortality. Aspirin for heart failure has no effect. But uh, if patients has ischemic heart disease, that would, that how it would be beneficial for ischemic heart disease? Not for heart failure itself. Ok. Very good. You all get it correct. What, what are other medications that would improve mortality in patients? Heart failure? Um We can also use uh uh uh I mean if someone else wants to answer before I do this. Mhm OK. So sodium sodium, sodium glucose like to two and uh also yes, it can also improve mortality. Good, good. And uh people said beta blockers with dilators s OK. Very good. Very good can cause receptor antagonist. Don't forget. Yeah. And the aldosterone uh antagonists like spironolactone. Yes, exactly. Bra can do it as well. I think you in selected patients very good in selected patients. Very good. So let's go to the next question. Oh, we need volunteers. Come on. Uh we need another person. We have. How many we have 30 people here. Come on guys. It's not just uh like to hear a new voice and even if you get it wrong, no problem. We are all here to know you can go for this. I will help. I will help the whoever will come here, I will help. A 5555 years old man is noted to have congestive heart failure. Oh and state that's east west. But because this neck even if it's walking to the bathroom, OK. Echocardiography is noted to have an ejection fra oops, sorry, I think I'm back. Um It's noted to have an ejection fraction of 47. Which of the following is the most is more a description um condition. Um II think um as a yes, systolic dysfunction. OK. Uh Do you remember the classific different classification based on ejection fraction? When we say it's uh heart failure is uh reduced vision fraction, mildly preserved or mildly reduced patient fraction and then arthritis preserved ejection fraction. Do you remember the cutoff? You are right? Because the answer is correct systolic dysfunction. You are correct. But do you remember the classification depending on the ejection fraction? If I say if I ask you which which class is this? Is it heart failure? It is reduced ejection fraction with mildly reduced ejection fraction or it is preserved ejection fraction. Yes, it's heart failure is mildly reduced ejection fraction, less than 4040 or less. This is heart failure with reduced ejection fraction, 50 or more with heart failure with preserved ejection fraction. In between heart failure is mildly reduced ejection fraction. But in, in uh if we wanna say is this systolic or diastolic more 50 or more. This is diastolic, less than 50. This is systolic systolic. Ok. Give me an example of a co of uh uh conditions that can result in systolic dysfunction. Just one exam os mortis. Mhm. Oros. Ok. And ischemic heart diseases. Also an example, give me an example of a condition can result in diastolic dysfunction, diastolic dysfunction, hypertrophic cardiomyopathy. Ok. Hypertension, restrictive cardiomyopathy as well. Ok. Pericarditis which can result in the in dilated cardiomyopathy. It is systolic, not diastolic. OK. Who is next face up? Are you able to join us? Uh You can go for it? Let's go. No judgment here. OK. OK. Yeah. Yeah. No, no, no. Mhm OK. OK. How much say you said furamide? Why do you think furamide is indicated? Yeah. Mhm. Why not a why not age approach? Mhm. Uh Male patients usually OK. Even when you answer these questions, fair thing to look for is this patient presented acutely by patients right now is severely congested or not. This is the fairest thing. If that's the case is this patient severely congested, then you might push you to go for of course, you should go for admission for uh diuretics. And so then there would be a priority because it would be life saving in acute setting. OK. If not, then we look immediately for the ejection fraction. Look immediately for the ejection fraction, which classes is his heart failure with M reduce. Yes. Minimally or mildly reduced ejection fraction is 45%. Ok. Then which drug, which of these drugs we could use the spironolactone we could use as inhibitor beta blocker. All we can use in patients with heart failure is mildly or minimal reduce injection fraction, digoxin. It can be used but at least the patient is on maximum treatment and patients with multiple admissions. Then we don't use digoxin because we need to refer from digoxin as much as we can implantable cardic defibrillator. This is for patients with advanced heart therape or are are on maximum therapy and we still and still they are symptomatic. So right now, digoxin is not indicated, implantable defibrillator is not indicated. Patient is not, it's not severely congested, right. So fide is not indicated. So either spironone ace inhibitor and beta blocker. All of the three are indicated. But which one is it better to start ace inhibitor and beta blocker or spinal duct alone. It's better to start ace inhibitor and beta blocker. Every patient with heart failure should be on angiotensin agent. OK. And most of the patients should be on beta blocker as well. So it's better if you can choose two answers. Can you, you choose A and B? But here is the best possible answer is B that's why we go with S in ra blocker. OK. Spironolactone is used in males is used in males because it has remarkable benefits. Yes, it has some side effects. Undesirable side effects, but not all patients uh develop uh uh not all patients have the side effects and some of these patients, they don't mind like OK, it's, it's beneficial for our condition. OK? We can tolerate the side effects. So you discuss this for every drug, you discuss the side effects with the patient and then the patient decides. OK. But for this question, the answer is b the answer is B ace inhibitor and blocker. OK. Yup, digoxin is not indicated right now. Fri patient is not on the medications of heart failure. We should start the goal, direct medical therapy first. Ok. We have 444 medications and we start gradually, we build up gradually when patient is on maximum medications and tell patients got admitted repeatedly from the heart failure, exacerbations, then we can start digoxin, we can start digox. Ok? Is it clear? Ok. You wanna, you wanna, I can read this, I'm not sure whether I'm gonna answer, but I can just give it a try. And a 70 year old woman was brought to the emergency department by her son for evaluation of shortness of breath. She has had a sensation of choking since last night. According to her son, for the past several weeks, she has had a dry cough at night and has been taking over the counter cough, uh, drops. The patient has had no chest pain, palpitations, back pain, abdominal symptoms or lightheadedness. She has a history of hypertension hyperlipidemia and type two diabetes mellitus. She has been refusing um statin therapy, uh, as she heard, statins um cause multiple side effects. The patient has also refused flu vaccinations over the last um several years. Her only admission occurred six years ago when she underwent um a spinal fusion of for her um lower back pain. She does not use tobacco, alcohol, illicit drugs. Family history is not significant temperature is 36.1 degree. BP is 170 by 120 pulse is 92 and respirations are 34. Um pulse oximetry is 85% on room air. Uh BMI is 29 bilateral crackles of lung examination. There are no heart murmurs, ecg shows normal sinus rhythm, increased voltage in the pericardial leads and T wave inversion. It leads V five and V six. Chest X ray is shown um in the exhibit oxygen is administered um via the 100% non rebreather face mask, which of the following are the most appropriate next step in management of this patient. It's quite a massive big question. Um intravenous broad spectrum antibiotics, intravenous, fide intravenous and methylprednisolone, intravenous, metoprolol, intravenous uh thrombolytics. OK. And do you have the xray? Yes, this is the X ray. So what do you think? I think the heart is a nauseous cardiomegaly seen? Yes, there's cardiomegaly. Uh-huh. What, what else do you see any pulmonary vascular markings? Yes. Uh In the right lung and the middle and the lower lobe. Yes. And there is also on the left, I can see there is uh some big lines. So possibly there is also pulmonary edema. Yep, there is large. So also there is pulmonary edema. Ok. So cardiomegaly increased p vascular markings and pulmonary edema. So let's go back, we can summarize the question. So we have shortness of breath, ok. Choking since last night and for several weeks of dry cough at night. Ok. And then she has multiple comorbidities, type of diabetes and just then vitals she has he's hypertensive. Ok. And R 34 of the kidney and hypo hypoxemic and there is bilateral crack outs and the A CG there is inversion in five V five V six. So what do you think is going on here? I thought there is some ischemic symptoms but I could be wrong. Yup. But to diagnose ischemia, you need the chest pain. Yeah, you need the ac changes or cardiac enzymes. You need two out of the three. We don't have chest pain here maybe, but you need two out of three. Chest pain is typical changes. Yeah. Right. And we don't have the cardiac enzymes. So we cannot say this is mhm. How do you think I should. Ok. Will do. Ok. ASHA, what do you think? Um I kind of concur it bull, pulmonary embolism, pulmonary embolism. Uh for it could, of course, it's one of the differential. But here we have from x-ray from the usually spinal embolism, x-ray usually is is normal. Usually it is normal. There could be some changes but usually it's normal. OK. And uh usually patient is tachycardic and usually there are, there is a sinus tachycardia on ECG on ECG but patient on sinus and there is another me another conditions that could explain all the symptoms and signs. Z that is no. What about acute failure, acute heart failure could explain the shortness of breath. The progressive uh nature of uh this symptom could explain the bilateral basal crackles. Could explain B5 b6. For example, from long standing hypertension infections, the heart uh could explain the hypoxemia, the pulmonary edema and the cardiomegaly on the chest X ray. All of this could be explained by the heart failure. So why we should say pulmonary pulmonary embolism? So what is the next step in management? Urgent intravenous, uh urgent intravenous therapy? It uh I'm just caught up between the B and C actually. So I don know what uh methylprednisolone. What is methylprednisone? Which class is this? See which class is methylprednisolone? I think it won't be methylprednisolone because uh I think it's more on them. I think it's it can be used as an antiinflammatory. But um it's more when there's an when those um acute exacerbation of symptoms relating to breathing. Yes, you look, you look for in the chat, you find the answer. Some people are helping you steroids. OK. Steroids and steroids. There is no any indication for steroids and heart failure, acute or chronic. No any indication I think. Right. Huh. It actually exacerbate the symptoms like because like it can cause uh increase. No, I don't think so. I don't think it's excessive by the symptoms. But metoprolol, some people say d metoprolol is beta blocker. Beta blocker is contraindicated in acute heart and advanced heart failure, acute and advanced. It's all indicated in patients with stable heart failure, stable heart failure. Ok. So it's me furamide patient is congested has shortness of breath from the pulmonary edema. We need to relieve this pulmonary edema. So the patient get better and hypoxic as well. So it gives the patient of course oxygen and immediately start on furamide IV furamide and most patients this should be enough. Ok. So IVF is a might then er did you run Asher? Are you here? And now I'm here doctor? Yeah, I have I think two or three. Yeah, the patient is placed on a noninvasive positive pressure ventilation but still appears somewhat uncomfortable. The lab results are as far as hemoglobin, 11.4 platelets. Um 180 leucocytes, 10,000 sodium, 131 potassium, 3.8 creatinine, 1.4. The 1st 2.1 level is negative repeat, BP is 176. Um 105 pulse is 82 respirations are 24. Uh oxygen saturation is 94. What is the best next step in the management of this patient, um intravenous digoxin, um IV, metoprolol, IV, um intravenous nitroglycerin, intravenous unfractioned, um unfractionated heparin. I think nitroglycerin is not indicated in this case. Um I think I'm more tempted with the IV metoprolol. Actually beta blockers after the IV diuretics is given. OK. Any other uh any other possibility? Yes. Uh As you remember, uh get heart failure, we start with uh diuretics. So if pain is so we can add nitrates, we can add nitrate unless the patient is hypotensive. This patient is hypertensive. So, nitrate will improve the symptoms of heart failure and help with high BP as well. OK. So nitrate is the answer. Digoxin mien both can be used but usually after after admission of nitroglycerin, still patient is still symptomatic. We can uh digoxin or miol is FF inhibitors. OK. Metoprolol, we said it's uh it's absolutely contraindicated right now. Heparin because if you think from the first, it, this is primary embolism as some people thought and give thrombotic and they say, oh, let's give hi. That's why it's uh they put hi. OK. So it's nitroglycerin. The answer is nitroglycerin Z item three, I think I hope is I can, the patient is responding well to treatment. The second troponin uh one level is negative, which of these tests is the most appropriate. Next step in the management of this patient. Uh coronary angiography, D dier, noncontrast ct of the chest and pulmonary function test and transthoracic echocardiogram. Ok. So what do you think patient now is, is stable? So what's next? What's next? We stabilize the patient? The patient now is diagnosed with heart failure this first time. So what's next? We need to classify the heart failure based on ejection fraction, right. Yeah. So how do we do that? I think it's, it's an echo actually. So, yes, echo. Yes, it's an echo. The echo, you classify the heart failure and you might find the cause of the heart failure as well. Yes, that's the transthoracic echocardio from there. He has transthoracic echocardiogram in in most of he has transthoracic because it's it's easier to be done much easier than transesophageal. So it's trans echocardiogram. OK. Coronary angiography might be indeed after echo. For example, if echocardiogram showed that this could be ischemia, then we might need to do coronary angiography later on. But right now, next step is echocardiogram. OK. Very good. Very good. OK. We have a clinical scenario. Uh Let me read this for you. An 80 year old man has presented to the emergency department complaining of severe shortness of breath. He has been feeling increasingly ST this neck over the last fortnight and he is now unable to walk even short distances before becoming short of breath and his legs feel heavy to lift. He is short of breath at night two and has gone from sleeping with three bellows to sleeping upright in his chair. He has a cough productive of process, pinkish sputum but has not experienced any fevers. He has history of hypertension and heart problems but has stopped taking his diuretic medication recently owing to urinary frequency and occasion incontinence. Ok. So 88 year old man, short, severe shortness of breath and has progressive symptoms with heavy legs. Ok. And then he has uh hypertension, other cardiac issues and he stopped using diuretics. Ok. On examination, the patient is unable to speak in full sentences. Owing to his dysnea on a cult, they are fine in spiry crackles in the lower and mid zones. Bilaterally, his heart rate is 96 BP, 1 50/90 a third heart sound is audible at the left and itch but no murmurs exist. His JVP is raised at eight centimeters. His ankles are swollen and they're spitting ede up to his knees, arterial blood gas measurements show hypoxia and chest X ray shows bilateral fluffy areas consistent with pulmonary infiltrates. So patient has congestive symptoms. Ok. So this is the chest X ray. This is the fluffy areas here. Um bilaterally, it's not that visible right now because maybe it's too small, but there is pulmonary edema and even there is pleural effusion from on the right side, on the on bilateral hip. So why has the patient become short of breath? Why has the patient become short of breath? I think probably increasing the fluid level. Actually, this is more um an acute exacerbation on the chronic congestive failure. And what did cause the fluid accumulation in this patient? Because he stopped the diuretics. Yes. Excellent, excellent. This patient stopped diuretic. Then after that, he started to accumulate fluids. So this is the what caused fluid accumulation and it's what resulted in the exacerbation of heart failure. Very nice. And then what would be the appropriate management for this patient? IV diuretics? Your this patient presented to you like this, I just give you my directives or how are you going to manage it? Yes, you are in the hospital. You are in the emergency room. This patient presented to you, I think so. Might I think. Yeah, but what would be your work up for this patient? Oh you try to do as uh extra diagnostic uh test. No, we admit the patient actually cause it's in, in a we admit the patient. Yep. OK. Admit where uh intensive care, cardiac intensive cardio. See, I see. OK, after that, after that, we started ABC. Is he starts airway breathing? We, we put him on CPAP because uh he's probably gonna uh so we put her on CPAP and uh uh it in 45 angle position. Uh and then we start the medications. OK. What's the first medication to be given? Uh furosemide if it doesn't work? Uh And it's still high, we can go for nitrates and high, high risk like situation. We can go morphine and like, OK, so you give, you have given patient uh furosemide nitrate and now patient is stable. What's next stable? We can uh uh like if the patient is like uh stable uh for uh enough duration, we can go from uh and uh echogram just to assess the um the, the uh OK. So look, this patient first will be admitted to the ICU given oxygen, either high flu oxygen or CPAP, then given uh furosemide might need nitrates, might need uh additional management for the condition. After the patient is stabilized. Uh We're gonna ask for uh PMP, serum electrolytes, renal functions, liver functions. And then af after that, we will gonna do echocardiography to see if we can find any cause and also what is ejection fraction and this patient will be managed according to his ejection ejection fraction. OK. So let's see for the chart. Mhm. Uh You mean for ischemic heart disease? If uh we need, we need to do a CG. Of course, if, if there is uh ischemic changes, we need to give aspirin and other medications for ischemic heart disease. Lung CT is not why lung CT I don't see any indication right now for CT. OK. And yeah, morphine, morphine will even if it ischemic heart disease, usually morphine is not advisable unless the patient is on severe pain regard, regardless of the initial management. Usually patients with ischemic heart disease after admission of nitrate administration of nitrates, uh they don't feel the pain like they have very remarkable improvement, indication of nitrate in acute heart failure. If pain is taken uh is given uh look, there is and still and still uh have shortage of breath or hypoxia and they are not hypotensive. They are not hypertensive. Ok. I think there was a question as a cat uh regarding the Ac and Arabs in patients heart failure, we usually in general AC is used first and if patient is intolerable, the AC usually use herbs but you can start herbs from the start. No problem. Vessels are not narrow here. So I would nitrate be needed nitrate because it decreases the preload of the heart and that decreases heart work out. OK? They decreases preload of the heart. That's why arthritis is given in heart failure in general. OK. Another question. Very good. So we finally finished our heart failure topic. OK. Feel free to reach, reach out to me anytime on Twitter or I write my name or my or uh username on telegram by this link or also this username. OK. Do you have any question you have? And I will be more than happy to, to ah OK. Wonderful. That's us then. So now we need to get you to do some other events, don't we? Um I think I think your ECG is that right? I think that's something that we've had a lot of more case studies to do with that. I think um So if anyone has any suggestions, you will get a feedback form, you should have got it 15 minutes ago. Um So do fill that out, do pop in some ideas. Um I've already taken some of Hussam feedback and had a look. Um So we do have some ideas already. Uh And I've asked Hussam what he can teach on. So I'm hoping that we'll get Husam on the platform on a regular basis and uh we can go from there. So do fill out your feedback form. Once you've done that, your attendance certificate will be on your medical account. Um And that sucks. Anything you want to add Sam. Yeah, the feedback is very important. It uh tell me how was the session and what to do for the next sessions as well. So it's one, it's one way of thanking our speakers, isn't it? It's a way of helping you learn and grow. Yeah. So, and I know that you're passionate about all. Exactly. Exactly. Apart from me because I just went straight over my head. So your feedback form will be on your medal account or it'll be in your inbox. Ok. Whichever, whichever one you'll find in your inbox should be right at the top. You should have got it about 11 o'clock and then um fill it out and then your atten certificate will be on your medal account. So we are gonna say goodbye. Have a lovely week. Um You take care and hopefully we'll see you at our next meal education event. We are actually because metal education has done so well. We are actually starting to, um, spread our wings a little bit. We've actually created metal oncology so that people who are interested in oncology, we can have speakers around that as well as threads and chat so that there can be more of a community vibe to that. We'll probably do the same with cardiology as well. Um We're just because of how we've grown with metal education, which I have to say came from our dear friend Maram who Sam knows Maram as well. Um She, she chatted with us. She's in Sudan, she chatted with us and that's how Metal education was birth. So we are now going even bigger and we are starting little subsections of middle education. So do look out for that. Do join the the specialities that you're really, really interested in. We'll keep middle education going anyway, but we'll just start having middle education is like mom and then she has lots of little Children underneath her. I think that's the best way to explain it. We can all understand that one. So please do sign up for events. Most of the events on Metal are free. There's some great ones coming from the Royal College of Surgeons of England. They will probably come with CPD points and you are part if you have signed up on medal and your profile is all up to date and you're from an LM IC. You will get free access because they've partnered with us to give free access to those in low or middle income countries. So please do make the most of that, honestly make the most of it. Um But anyway, we will say goodbye to you for now. I stop waffling. We'll say goodbye to you and watch out for HS in the future when he starts doing other teaching. Ok. We'll say goodbye now. Thank you, everyone. Just a, just a second. Uh I see there is a question or I think if I read the name correctly, main difference between pulm and, and pleural effusion from the pulmonary edema. It's inside the lungs, the fluids accumulated inside the l and pleural effusion. It's in the pleural around the lungs. Ok. So this is the difference just like, ok, perfect. I just let Sam deal with all those questions. I'll just to, that's all I do. I'll just arrange the events right. Anyway, everyone have a lovely week and we'll see you at our next events. All right. Take care. Everyone see you.