WEBVTT 00:00:00.256 --> 00:00:02.731 Her ejection fraction is sixty-three percent. 00:00:03.115 --> 00:00:05.525 She still cannot finish the walk she used to enjoy. 00:00:05.803 --> 00:00:08.299 A reassuring number has not explained what changed. 00:00:08.619 --> 00:00:10.921 Welcome to HEART RESERVE Clinical Conversations. 00:00:11.218 --> 00:00:15.101 I’m Lisa Zahakos, a physician assistant and founder of HEART RESERVE. 00:00:15.442 --> 00:00:19.709 In this episode, we’ll follow Renee with unexplained breathlessness, Angela with a 00:00:19.752 --> 00:00:22.729 treatment decision, and Teresa after a hospitalization. 00:00:23.105 --> 00:00:25.366 These are fictional teaching cases for clinicians. 00:00:25.622 --> 00:00:28.822 You can listen straight through, or use the chapters to return to 00:00:28.864 --> 00:00:31.894 a case. I’ll ask you to consider a few decisions and then 00:00:31.979 --> 00:00:35.929 walk through the reasoning. The activity page has the objectives, references and 00:00:35.972 --> 00:00:41.190 online questions. This episode focuses on heart failure with preserved ejection fraction. 00:00:41.586 --> 00:00:46.151 The syndrome requires more than a pumping percentage: symptoms or signs must 00:00:46.237 --> 00:00:48.452 be connected to objective cardiac evidence. 00:00:48.832 --> 00:00:53.995 Ejection fraction categories, trial entry criteria and product indications are related but 00:00:54.037 --> 00:00:58.290 are not interchangeable. Under the 2022 U S guideline and historical trial 00:00:58.375 --> 00:01:03.367 terminology, heart failure with preserved ejection fraction refers to a left ventricular 00:01:03.495 --> 00:01:07.828 ejection fraction of at least 50 percent; heart failure with mildly reduced 00:01:07.913 --> 00:01:11.282 ejection fraction refers to 41 to 49 percent. 00:01:11.665 --> 00:01:16.913 The 2026 European Society of Cardiology guideline instead uses reduced ejection fraction 00:01:17.169 --> 00:01:21.393 for values below 50 percent and preserved ejection fraction for values of 00:01:21.435 --> 00:01:25.464 at least 50 percent, removing the separate mildly reduced category. 00:01:25.720 --> 00:01:30.286 Identify the guideline framework. These naming changes do not alter completed trials 00:01:30.456 --> 00:01:35.307 or U S product-label boundaries. Several trials and the finerenone heart-failure indication 00:01:35.563 --> 00:01:39.190 include left ventricular ejection fraction of at least 40 percent. 00:01:39.574 --> 00:01:42.487 Always read the actual study or label boundary. 00:01:42.756 --> 00:01:45.956 The women’s-health focus is a reason to ask a fuller history and 00:01:46.041 --> 00:01:49.455 examine care gaps. It is not a claim that every woman has 00:01:49.540 --> 00:01:52.569 the same phenotype or that a medicine works better simply because the 00:01:52.612 --> 00:01:58.096 patient is a woman. Pregnancy history, blood pressure, metabolic disease, kidney health, 00:01:58.309 --> 00:02:01.844 function and access belong in one clinical story. 00:02:02.352 --> 00:02:05.808 Let’s begin with Renee. Renee used to walk the school track while 00:02:05.851 --> 00:02:09.392 her daughter practiced. Over six months she has begun stopping after one 00:02:09.477 --> 00:02:13.759 lap. The report says left ventricular ejection fraction 63 percent. 00:02:14.073 --> 00:02:15.716 She was told the result was reassuring. 00:02:15.950 --> 00:02:18.126 She wants to know why activity has become harder. 00:02:18.425 --> 00:02:23.886 Presentation. Stable exertional dyspnea; no new chest pain, syncope or breathlessness at 00:02:23.929 --> 00:02:30.094 rest. Context. body mass index 37 kilograms per square meter; hypertension; remote 00:02:30.137 --> 00:02:36.483 severe preeclampsia. Available tests. left ventricular ejection fraction 63 percent; N T 00:02:36.568 --> 00:02:40.792 pro B N P 88 picograms per milliliter; full echo parameters not 00:02:40.835 --> 00:02:45.336 yet reviewed. Clinical task. Keep the differential open and obtain the evidence 00:02:45.592 --> 00:02:48.664 needed to explain the symptom. Begin with the change in her life. 00:02:48.920 --> 00:02:52.120 Ask Renee to describe a usual day before and after the symptoms 00:02:52.248 --> 00:02:55.899 began. A comparison with her own baseline is more useful than asking 00:02:56.113 --> 00:02:58.993 only whether she can exercise. How far does she walk? 00:02:59.228 --> 00:03:03.494 Does she stop because of breathlessness, fatigue, chest discomfort, pain or fear 00:03:03.579 --> 00:03:06.157 of falling? Is the limitation reproducible? 00:03:06.413 --> 00:03:08.184 Has the pace of decline changed? 00:03:08.547 --> 00:03:11.811 Establish the timeline before interpreting any single result. 00:03:12.131 --> 00:03:16.173 Then separate a stable outpatient problem from a potentially unstable one. 00:03:16.418 --> 00:03:22.306 New breathlessness at rest, chest pressure, syncope, severe hypoxemia or rapidly progressive 00:03:22.477 --> 00:03:26.007 symptoms require urgent assessment according to the presentation. 00:03:26.381 --> 00:03:30.136 The reassuring wording on an old echocardiogram must not override a new 00:03:30.178 --> 00:03:35.597 concerning symptom. Renee’s initial presentation is stable; that permits a structured evaluation, 00:03:35.810 --> 00:03:42.319 not a dismissal. Ask about orthopnea, waking breathless, edema, weight change, palpitations, 00:03:42.703 --> 00:03:45.455 sleep-disordered breathing and exertional chest symptoms. 00:03:45.732 --> 00:03:52.370 Reconcile prescribed and nonprescribed medicines. Review blood pressure history, atrial fibrillation, kidney 00:03:52.413 --> 00:03:57.159 disease, diabetes, valve disease and previous cardiovascular testing. 00:03:57.468 --> 00:04:01.521 A description such as 'deconditioned' may eventually be reasonable, but it should 00:04:01.607 --> 00:04:03.954 not replace the assessment needed to support it. 00:04:04.252 --> 00:04:08.210 What a preserved ejection fraction can, and cannot, tell you. 00:04:08.499 --> 00:04:12.894 Ejection fraction is the proportion of end-diastolic ventricular volume ejected with a 00:04:12.936 --> 00:04:17.288 beat. It does not directly measure filling pressure, reserve during exercise or 00:04:17.331 --> 00:04:19.580 the total burden of a multisystem illness. 00:04:19.909 --> 00:04:23.664 A woman can have preserved left ventricular ejection fraction and still have 00:04:23.706 --> 00:04:28.016 a clinically important limitation in filling, vascular function or the response to 00:04:28.101 --> 00:04:33.081 exertion. Conversely, an ejection fraction of 63 percent is not evidence by 00:04:33.124 --> 00:04:36.559 itself that heart failure with preserved ejection fraction is present. 00:04:36.836 --> 00:04:39.812 Read the entire echocardiogram in clinical context. 00:04:40.144 --> 00:04:45.946 Review chamber size, left atrial volume, wall thickness, tissue Doppler measurements, estimated 00:04:46.074 --> 00:04:49.808 filling-pressure indices, right-sided findings and valve assessment. 00:04:50.042 --> 00:04:54.244 Image quality and rhythm matter. A report of 'diastolic dysfunction' does not 00:04:54.286 --> 00:04:58.767 automatically establish symptomatic heart failure; an apparently normal resting study does not 00:04:58.809 --> 00:05:03.608 necessarily explain exertional symptoms. Do not calculate a diagnostic score with missing 00:05:03.778 --> 00:05:07.874 inputs. Renee’s ejection fraction and N T pro B N P do 00:05:07.917 --> 00:05:15.453 not supply the information required for a complete H2FPEF or HFA-PEFF assessment. 00:05:15.608 --> 00:05:19.235 A score can organize uncertainty when used in the population and context 00:05:19.320 --> 00:05:22.264 for which it was designed. Its output should help decide the next 00:05:22.435 --> 00:05:25.346 step, not substitute for reasoning. Here is the decision. 00:05:25.656 --> 00:05:29.538 Which information would most help determine whether Renee’s evaluation is on the 00:05:29.581 --> 00:05:32.226 right track? Pause here if you would like a moment to think 00:05:32.269 --> 00:05:35.632 it through. The best next step in this case is: Review the 00:05:35.675 --> 00:05:40.347 symptom trajectory, examination, full echo findings and competing causes. 00:05:40.667 --> 00:05:44.434 These findings connect her functional change to a focused diagnostic plan. 00:05:44.703 --> 00:05:47.284 Use biomarkers without letting them close the case. 00:05:47.646 --> 00:05:51.589 Natriuretic peptides are useful, but obesity can lower their concentrations. 00:05:51.991 --> 00:05:55.703 An unflagged value is therefore less reassuring when the clinical question is 00:05:55.788 --> 00:05:59.585 heart failure with preserved ejection fraction in a woman with obesity and 00:05:59.671 --> 00:06:05.117 exertional symptoms. Other conditions, including atrial fibrillation and kidney dysfunction, can also 00:06:05.287 --> 00:06:11.389 alter interpretation. Use the actual value, units, assay and context rather than 00:06:11.431 --> 00:06:17.151 the laboratory flag alone. A selected 2024 research cohort illustrates this problem. 00:06:17.450 --> 00:06:22.421 Among 78 volunteers with obesity and dyspnea, 65 percent were women. 00:06:22.613 --> 00:06:27.093 Forty qualified for invasive exercise testing; 24 were found to have heart 00:06:27.178 --> 00:06:31.189 failure with preserved ejection fraction. That is 60 percent of those tested 00:06:31.317 --> 00:06:33.694 and 31 percent of the full sample. 00:06:33.981 --> 00:06:38.503 Resting N T pro B N P and echocardiographic measures did not 00:06:38.546 --> 00:06:42.812 clearly separate the groups. These findings support a diagnostic concern; they are 00:06:42.855 --> 00:06:46.065 not a population prevalence estimate for all women with obesity. 00:06:46.374 --> 00:06:50.426 For Renee, the practical response is to obtain the missing information and 00:06:50.469 --> 00:06:54.591 reconsider the competing explanations. It is not to diagnose heart failure with 00:06:54.634 --> 00:06:58.815 preserved ejection fraction from body mass index, start every heart failure medicine 00:06:58.858 --> 00:07:03.221 empirically, or reassure her solely because the laboratory result was not flagged. 00:07:03.489 --> 00:07:07.670 Make the differential explicit. heart failure with preserved ejection fraction is one 00:07:07.713 --> 00:07:10.076 explanation for breathlessness, not the only one. 00:07:10.348 --> 00:07:15.894 The first evaluation commonly includes a focused examination, ECG, appropriate laboratory testing 00:07:16.023 --> 00:07:19.250 and review of imaging. Testing should be selected to answer the clinical 00:07:19.378 --> 00:07:25.735 question: anemia, pulmonary disease, rhythm disturbance, ischemia, significant valve disease and other 00:07:25.864 --> 00:07:30.414 causes may need consideration. Obesity can coexist with each of these conditions. 00:07:30.798 --> 00:07:35.107 Some disorders can resemble heart failure with preserved ejection fraction yet require 00:07:35.279 --> 00:07:37.426 a different diagnostic and treatment pathway. 00:07:37.697 --> 00:07:43.371 Clues to infiltrative cardiomyopathy, constrictive physiology or important valve disease should prompt 00:07:43.414 --> 00:07:49.098 directed evaluation. Do not label every thickened ventricle as ordinary hypertensive remodeling. 00:07:49.405 --> 00:07:53.288 Equally, do not send every patient with dyspnea for every advanced test; 00:07:53.544 --> 00:07:56.871 use the history and first-line findings to choose what will resolve the 00:07:56.914 --> 00:08:01.487 uncertainty. Document both the leading hypothesis and the reason it remains uncertain. 00:08:01.666 --> 00:08:06.495 'Possible heart failure with preserved ejection fraction; full echo and alternate causes 00:08:06.580 --> 00:08:10.326 under review' is more useful than a premature definitive diagnosis. 00:08:10.615 --> 00:08:14.241 That distinction also protects later treatment decisions from being based on a 00:08:14.284 --> 00:08:19.269 diagnosis that was never confirmed. When resting data leave an intermediate probability. 00:08:19.602 --> 00:08:26.130 The HFA-PEFF framework uses clinical assessment, echocardiographic and natriuretic-peptide evidence, functional testing 00:08:26.216 --> 00:08:29.748 when uncertainty remains, and a final search for the underlying cause. 00:08:30.080 --> 00:08:35.876 The H2FPEF approach estimates diagnostic likelihood from clinical and echocardiographic features. 00:08:36.296 --> 00:08:40.733 These tools answer related questions with different inputs; disagreement or an intermediate 00:08:40.776 --> 00:08:43.970 result is a reason to review the evidence, not average the scores. 00:08:44.304 --> 00:08:47.739 In a symptomatic patient whose resting findings do not resolve the question, 00:08:48.059 --> 00:08:53.725 specialist assessment may lead to exercise echocardiography or invasive exercise hemodynamics. 00:08:54.058 --> 00:08:58.324 The choice depends on the remaining uncertainty, local expertise, feasibility and the 00:08:58.367 --> 00:09:03.274 patient’s circumstances. A normal resting pressure cannot necessarily answer what happens during 00:09:03.317 --> 00:09:06.876 the activity that produces symptoms. Explain the purpose of the referral in 00:09:06.919 --> 00:09:12.252 the order: 'Persistent exertional dyspnea with obesity and hypertension, preserved ejection fraction, 00:09:12.551 --> 00:09:17.786 nondiagnostic resting assessment; please evaluate for heart failure with preserved ejection fraction 00:09:18.043 --> 00:09:22.558 and mimics.' Include the actual tests, symptom trajectory and question. 00:09:22.936 --> 00:09:26.221 This gives the receiving clinician a starting point and makes it easier 00:09:26.477 --> 00:09:29.058 to recognize whether the referral has answered the question. 00:09:29.506 --> 00:09:32.206 Bring the history forward without overinterpreting it. 00:09:32.430 --> 00:09:35.886 Renee remembers severe preeclampsia but has never been asked about it in 00:09:35.929 --> 00:09:39.555 a general medical visit. Record the condition and timing as part of 00:09:39.598 --> 00:09:44.020 her cardiovascular history. It may strengthen the prevention conversation, but it cannot 00:09:44.276 --> 00:09:46.342 establish the cause of her current dyspnea. 00:09:46.616 --> 00:09:51.715 Pregnancy complications are not interchangeable with a past diagnosis of peripartum cardiomyopathy, 00:09:51.864 --> 00:09:54.057 and neither should be inferred without evidence. 00:09:54.458 --> 00:09:57.743 Ask what she understood from the earlier test: 'When you heard that 00:09:57.786 --> 00:10:00.644 the pumping percentage was normal, did you think that meant there could 00:10:00.687 --> 00:10:04.902 not be a heart problem?' Then correct the misunderstanding without creating unnecessary 00:10:05.201 --> 00:10:07.804 certainty: 'The pumping percentage is preserved. 00:10:08.017 --> 00:10:10.684 We still need to understand why activity has become harder. 00:10:10.919 --> 00:10:15.124 We are checking heart and nonheart causes.' Close with a concrete plan: 00:10:15.380 --> 00:10:19.177 the next test or consultation, who tracks it, how she receives the 00:10:19.220 --> 00:10:21.673 result and which new symptoms change the urgency. 00:10:21.865 --> 00:10:25.875 If transportation or cost makes the planned test unrealistic, address that before 00:10:26.046 --> 00:10:29.374 ending the visit. The outcome of this encounter is an explained next 00:10:29.502 --> 00:10:32.148 step, not simply a referral entered in the chart. 00:10:32.532 --> 00:10:36.879 Here is the decision. After reviewing the resting data, uncertainty remains. 00:10:37.114 --> 00:10:39.354 Which referral best communicates the clinical need? 00:10:39.460 --> 00:10:41.758 Pause here if you would like a moment to think it through. 00:10:42.050 --> 00:10:46.465 The best next step in this case is: Describe persistent exertional symptoms, 00:10:46.700 --> 00:10:50.497 available findings, alternatives and the question of exercise evaluation. 00:10:50.839 --> 00:10:54.791 A focused referral makes the uncertainty and desired next decision clear. 00:10:55.073 --> 00:10:59.638 The takeaway: Preserved ejection fraction and a low natriuretic peptide do not 00:10:59.766 --> 00:11:02.625 end the evaluation of persistent exertional symptoms. 00:11:02.924 --> 00:11:07.379 Confirm the syndrome, examine alternatives and track the next diagnostic step. 00:11:07.952 --> 00:11:10.896 Before we move on, let’s apply that reasoning in more detail. 00:11:11.195 --> 00:11:14.310 Test the reassurance: a worked diagnostic reveal. 00:11:14.523 --> 00:11:17.399 Return to Renee after the complete resting evaluation. 00:11:17.672 --> 00:11:21.427 There is no major valve lesion, no clear anemia and no sustained 00:11:21.512 --> 00:11:25.395 tachyarrhythmia. A complete H F A peff assessment is intermediate. 00:11:25.651 --> 00:11:28.947 This does not turn a nondiagnostic study into a negative study. 00:11:29.214 --> 00:11:33.224 Her symptom occurs during exertion; a resting measurement may not reproduce the 00:11:33.267 --> 00:11:37.747 physiology causing it. The next question is which functional assessment can resolve 00:11:37.790 --> 00:11:43.438 the uncertainty and change management. If specialist exercise echocardiography remains inconclusive or 00:11:43.523 --> 00:11:47.704 is not feasible, invasive exercise hemodynamics may be appropriate in a center 00:11:47.918 --> 00:11:51.865 with the required expertise. Explain what the additional test will answer, its 00:11:51.950 --> 00:11:56.208 burdens and the alternatives. Do not assume that everyone with obesity needs 00:11:56.293 --> 00:12:01.157 catheterization; persistent symptoms, the probability of disease and the consequences of the 00:12:01.200 --> 00:12:07.153 result drive the decision. A 2025 study using selected outpatient diagnostic cohorts 00:12:07.281 --> 00:12:10.481 found that the usual N T pro B N P threshold of 00:12:10.524 --> 00:12:15.473 125 picograms per milliliter had sensitivity of 82 percent when body mass 00:12:16.132 --> 00:12:20.228 index was below 35 and 67 percent when body mass index was 00:12:20.271 --> 00:12:24.526 at least 35. This supports caution about a low value in Renee. 00:12:24.814 --> 00:12:28.312 It does not establish a new universal threshold or a screening test 00:12:28.440 --> 00:12:34.030 for asymptomatic people. Atrial fibrillation and kidney dysfunction can raise concentrations, while 00:12:34.072 --> 00:12:38.444 obesity can lower them. A single laboratory flag cannot resolve those competing 00:12:38.657 --> 00:12:43.820 influences. Before referral, state one sentence that states the clinical uncertainty and 00:12:43.905 --> 00:12:45.647 one that states the functional loss. 00:12:45.981 --> 00:12:50.802 Then attach the actual echo measurements, rhythm, biomarker value, blood pressure history 00:12:51.144 --> 00:12:55.069 and relevant testing. Ask the receiving team to report both the diagnostic 00:12:55.154 --> 00:12:58.405 conclusion and the next treatment or follow-up responsibility. 00:12:58.711 --> 00:13:02.593 A referral succeeds when its answer returns to the clinician and patient 00:13:02.892 --> 00:13:05.314 who need it. Now meet Angela. 00:13:05.549 --> 00:13:08.002 Her heart failure diagnosis has been confirmed. 00:13:08.237 --> 00:13:11.778 Angela has confirmed heart failure with preserved ejection fraction. 00:13:12.120 --> 00:13:15.149 A diuretic helped her edema, but she still stops on the walk 00:13:15.234 --> 00:13:19.069 to her mailbox. She asks whether heart-failure medicines can help when she 00:13:19.112 --> 00:13:22.288 does not have diabetes. Established diagnosis. 00:13:22.562 --> 00:13:27.448 heart failure with preserved ejection fraction confirmed after clinical and objective assessment; 00:13:27.640 --> 00:13:30.584 left ventricular ejection fraction 58 percent. 00:13:31.010 --> 00:13:36.156 Current context. body mass index 35 kilograms per square meter; A one 00:13:36.241 --> 00:13:40.797 C 5.8 percent; no diabetes. Safety starting point. 00:13:41.044 --> 00:13:44.329 E G F R 48 milliliters per minute per one point seven 00:13:44.415 --> 00:13:50.004 three square meters; potassium 4.6 milliequivalents per liter; review current volume status. 00:13:50.217 --> 00:13:54.256 Patient goal. Walk to the mailbox with fewer stops; preserve strength and 00:13:54.299 --> 00:13:58.306 independence. Match each treatment to the problem it is meant to solve. 00:13:58.601 --> 00:14:04.105 Begin with current congestion, blood pressure, kidney function, rhythm, comorbidities, medication access 00:14:04.489 --> 00:14:08.364 and Angela’s goal. A drug that relieves fluid overload and a therapy 00:14:08.407 --> 00:14:11.948 that reduces future heart failure events may both have a role, but 00:14:11.991 --> 00:14:15.703 their purposes should be clear. Do not use improved edema as evidence 00:14:15.916 --> 00:14:17.823 that the overall risk has disappeared. 00:14:18.151 --> 00:14:23.399 Contemporary heart failure with preserved ejection fraction care integrates heart failure-directed treatment 00:14:23.527 --> 00:14:29.756 with management of obesity, diabetes when present, hypertension, kidney disease, atrial fibrillation 00:14:30.012 --> 00:14:35.836 and coronary disease. The 2026 American College of Cardiology update incorporates newer 00:14:35.878 --> 00:14:41.169 evidence for S G L T 2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists 00:14:41.340 --> 00:14:44.421 and incretin-based therapies within that broader approach. 00:14:44.771 --> 00:14:47.502 This is not a direction to give every agent to every patient 00:14:47.672 --> 00:14:51.256 in a fixed sequence. Ask what Angela is already taking, what she 00:14:51.299 --> 00:14:55.252 has previously stopped and why. A medication list may contain an agent 00:14:55.295 --> 00:14:58.085 she never obtained or a dose she no longer uses. 00:14:58.442 --> 00:15:03.306 Explain the expected benefit in terms that match the evidence: symptoms, worsening 00:15:03.391 --> 00:15:07.253 heart failure events, hospitalization or another measured endpoint. 00:15:07.658 --> 00:15:11.377 Avoid promising an individual outcome from an average trial result. 00:15:11.725 --> 00:15:15.522 S G L T 2 inhibition is not restricted to patients with 00:15:15.565 --> 00:15:23.103 diabetes. In EMPEROR-Preserved, 5,988 participants with symptomatic heart failure and left ventricular 00:15:23.231 --> 00:15:27.722 ejection fraction above 40 percent received empagliflozin or placebo. 00:15:28.032 --> 00:15:32.725 The primary composite of cardiovascular death or heart failure hospitalization occurred in 00:15:32.768 --> 00:15:39.150 13.8 percent versus 17.1 percent; the hazard ratio was 0.79 (95 percent 00:15:39.406 --> 00:15:45.454 confidence interval 0.69 to 0.90). The effect was largely driven by fewer 00:15:45.496 --> 00:15:49.669 heart failure hospitalizations and was observed with and without diabetes. 00:15:49.959 --> 00:15:56.487 DELIVER tested dapagliflozin in 6,263 participants with left ventricular ejection fraction above 00:15:56.530 --> 00:16:02.102 40 percent. Worsening heart failure or cardiovascular death occurred in 16.4 percent 00:16:02.401 --> 00:16:08.527 versus 19.5 percent, with a hazard ratio of 0.82 (95 percent confidence 00:16:08.740 --> 00:16:14.756 interval 0.73 to 0.92). The trials support heart failure treatment beyond glucose 00:16:14.841 --> 00:16:18.057 lowering. They do not show that one S G L T 2 00:16:18.099 --> 00:16:19.849 inhibitor is superior to the other. 00:16:20.147 --> 00:16:23.774 Angela’s absence of diabetes is therefore not a reason by itself to 00:16:23.859 --> 00:16:26.582 exclude an appropriate S G L T 2 inhibitor. 00:16:26.872 --> 00:16:32.888 Review the selected product’s heart failure indication, renal-use instructions, volume status, contraindications 00:16:33.144 --> 00:16:38.512 and access. Discuss genital infection symptoms, volume depletion and the possibility of 00:16:38.555 --> 00:16:45.156 ketoacidosis even without marked hyperglycemia. Provide individualized instructions for illness, fasting and 00:16:45.198 --> 00:16:50.105 procedures; empagliflozin’s label specifies withholding for at least three days before surgery 00:16:50.233 --> 00:16:53.337 or procedures associated with prolonged fasting, when possible. 00:16:53.710 --> 00:16:56.868 Do not turn a monitoring conversation into a list the patient cannot 00:16:56.996 --> 00:17:00.708 use. Ask Angela which instruction she would follow if she were unable 00:17:00.836 --> 00:17:04.086 to eat or drink. Clarify whom she calls and when. 00:17:04.393 --> 00:17:08.105 Coordinate any diuretic adjustment with her volume assessment and the prescribing team 00:17:08.233 --> 00:17:11.604 rather than giving a universal instruction to reduce or stop it. 00:17:11.860 --> 00:17:15.933 Here is the decision. Angela asks why a medicine commonly discussed for 00:17:15.976 --> 00:17:19.816 diabetes is being considered. Which answer is most accurate? 00:17:20.071 --> 00:17:22.325 Pause here if you would like a moment to think it through. 00:17:22.573 --> 00:17:25.517 The best next step in this case is: It is being considered 00:17:25.687 --> 00:17:29.250 for heart failure benefit; the evidence includes people without diabetes. 00:17:29.527 --> 00:17:32.801 The indication and evidence should be explained in heart failure terms. 00:17:33.131 --> 00:17:36.038 What the newer obesity trials actually establish. 00:17:36.586 --> 00:17:42.260 STEP H F peff studied semaglutide 2.4 milligrams in 529 participants with 00:17:42.303 --> 00:17:46.546 obesity and heart failure with preserved ejection fraction without diabetes. 00:17:46.735 --> 00:17:52.325 At 52 weeks, the between-group improvement in Kansas City Cardiomyopathy Questionnaire clinical 00:17:52.495 --> 00:17:57.989 summary score was 7.8 points, and weight reduction was greater with semaglutide. 00:17:58.277 --> 00:18:02.330 The main lesson is improvement in symptoms, physical limitations and weight in 00:18:02.373 --> 00:18:05.547 the studied population. It was not a mortality trial. 00:18:05.821 --> 00:18:11.837 SUMMIT studied tirzepatide in 731 participants with obesity and left ventricular ejection 00:18:12.050 --> 00:18:13.833 fraction of at least 50 percent. 00:18:14.208 --> 00:18:19.499 Cardiovascular death or worsening heart failure occurred in 9.9 percent versus 15.3 00:18:19.595 --> 00:18:27.014 percent (hazard ratio 0.62, 95 percent confidence interval 0.41 to 0.95). 00:18:27.199 --> 00:18:31.295 Fewer worsening heart failure events drove the result; cardiovascular death alone was 00:18:31.338 --> 00:18:34.823 not shown to be reduced. These trials ask different questions and cannot 00:18:34.993 --> 00:18:36.551 be used as a head-to-head ranking. 00:18:36.914 --> 00:18:40.621 Their effect sizes use different endpoints, populations and follow-up. 00:18:40.915 --> 00:18:44.840 Weight loss, symptom improvement and clinical event reduction should not be collapsed 00:18:44.883 --> 00:18:48.403 into a single claim that all incretin therapies do the same thing. 00:18:48.637 --> 00:18:51.020 Current US product indications also matter. 00:18:51.354 --> 00:18:56.644 The reviewed Wegovy and Zepbound labels contain obesity-related indications; the reviewed Zepbound 00:18:56.729 --> 00:19:00.538 label also includes obstructive sleep apnea in adults with obesity. 00:19:00.805 --> 00:19:04.005 Neither should be described here as carrying a specific heart failure with 00:19:04.090 --> 00:19:08.179 preserved ejection fraction indication. A clinician may use a medicine for an 00:19:08.221 --> 00:19:11.848 approved obesity indication in a patient who also has heart failure with 00:19:11.933 --> 00:19:16.371 preserved ejection fraction, while discussing heart failure with preserved ejection fraction trial 00:19:16.413 --> 00:19:20.659 evidence accurately. Verify the current exact label at prescribing and at course 00:19:20.745 --> 00:19:24.435 release. What belongs in an individualized obesity conversation. 00:19:24.841 --> 00:19:28.521 Ask permission to discuss weight and the symptoms that matter to Angela. 00:19:28.831 --> 00:19:31.648 Her goal is not simply a lower number: she wants to reach 00:19:31.776 --> 00:19:34.353 the mailbox and manage her daily responsibilities. 00:19:34.754 --> 00:19:39.106 Discuss treatment options in the context of access, preferences, other conditions and 00:19:39.149 --> 00:19:41.367 the ability to sustain nutrition and function. 00:19:41.751 --> 00:19:45.666 Review the selected agent’s contraindications, precautions and interactions. 00:19:46.083 --> 00:19:52.141 For semaglutide and tirzepatide, the relevant labeling includes the medullary thyroid carcinoma/multiple 00:19:52.397 --> 00:19:59.074 endocrine neoplasia type 2 contraindication and important gastrointestinal, gallbladder, pancreatitis and other 00:19:59.202 --> 00:20:02.743 precautions. This case is not a dose-escalation protocol. 00:20:02.999 --> 00:20:07.025 Use the product-specific prescribing information and the patient’s clinical context. 00:20:07.339 --> 00:20:12.075 Ask whether nausea, food insecurity, dental problems or living alone interfere with 00:20:12.118 --> 00:20:17.035 intake. A registered dietitian can help individualize nutrition while protecting function. 00:20:17.429 --> 00:20:21.227 Do not assign a universal protein, fluid or sodium prescription from this 00:20:21.312 --> 00:20:25.707 vignette; heart failure symptoms, kidney disease and nutritional status can change what 00:20:25.749 --> 00:20:30.985 is appropriate. Adapt physical activity to stability, symptoms and ability, and revisit 00:20:31.155 --> 00:20:33.566 strength and daily function as weight changes. 00:20:34.142 --> 00:20:38.396 At follow-up, ask what was obtained, what was tolerated and what changed. 00:20:38.724 --> 00:20:42.948 Include symptoms and a functional goal alongside weight, blood pressure and laboratory 00:20:43.076 --> 00:20:47.556 findings. A change in weight could reflect fluid, nutritional intake or intentional 00:20:47.684 --> 00:20:53.973 loss; interpreting it requires context. Read mineralocorticoid receptor antagonist evidence without assuming 00:20:54.016 --> 00:20:59.489 a class effect. Mineralocorticoid receptor antagonists are not interchangeable evidence packages. 00:20:59.842 --> 00:21:06.492 Spironolactone and eplerenone are steroidal mineralocorticoid receptor antagonists; finerenone is nonsteroidal. 00:21:06.786 --> 00:21:11.650 Receptor selectivity and pharmacologic properties differ, but a mechanistic difference does not 00:21:11.778 --> 00:21:17.824 establish comparative clinical superiority. In TOPCAT, spironolactone did not significantly reduce the 00:21:17.867 --> 00:21:22.133 overall primary composite endpoint in the studied heart failure with preserved ejection 00:21:22.304 --> 00:21:27.835 fraction population. heart failure hospitalization was lower, and hyperkalemia was more frequent. 00:21:28.133 --> 00:21:33.493 Important regional differences complicate interpretation. Selected patients may still have reasons for 00:21:33.536 --> 00:21:37.674 a steroidal mineralocorticoid receptor antagonist, but the result should not be described 00:21:37.802 --> 00:21:42.436 as an unequivocally positive overall heart failure with preserved ejection fraction trial. 00:21:42.973 --> 00:21:48.690 In FINEARTS H F, 6,001 participants with left ventricular ejection fraction of 00:21:48.733 --> 00:21:52.700 at least 40 percent were randomized to finerenone or placebo. 00:21:52.956 --> 00:21:56.668 The composite rate of total worsening heart failure events and cardiovascular death 00:21:56.796 --> 00:22:03.253 was lower with finerenone (rate ratio 0.84, 95 percent confidence interval 0.74 00:22:03.449 --> 00:22:08.221 to 0.95). Cardiovascular death alone was not significantly reduced. 00:22:08.370 --> 00:22:13.149 Hyperkalemia was more frequent. Its current heart failure indication and monitoring requirements 00:22:13.234 --> 00:22:17.402 are addressed in Teresa’s case. Do not compare TOPCAT and FINEARTS H 00:22:17.573 --> 00:22:21.790 F as though patients were randomized between spironolactone and finerenone. 00:22:22.081 --> 00:22:27.671 Do not stack two mineralocorticoid receptor antagonists without a specific specialist-directed reason 00:22:27.841 --> 00:22:32.492 and a careful safety review. The treatment decision should identify the indication, 00:22:32.748 --> 00:22:34.675 the evidence and the monitoring burden. 00:22:34.866 --> 00:22:38.828 Separate a pooled analysis from a heart failure with preserved ejection fraction 00:22:39.000 --> 00:22:44.265 trial. FINE-HEART pooled participant-level data from FIDELIO D K D, FIGARO D 00:22:44.309 --> 00:22:46.263 K D and FINEARTS H F. 00:22:46.504 --> 00:22:52.739 Its 18,991 participants span chronic kidney disease with type 2 diabetes and 00:22:52.783 --> 00:22:56.285 heart failure with mildly reduced or preserved ejection fraction. 00:22:56.626 --> 00:22:59.524 It is not a new head-to-head trial and is not a heart 00:22:59.612 --> 00:23:02.572 failure with preserved ejection fraction-only population. 00:23:02.940 --> 00:23:09.570 Its primary cardiovascular-death result did not reach statistical significance (hazard ratio 0.89, 00:23:09.659 --> 00:23:14.208 95 percent confidence interval 0.78 to 1.01). 00:23:14.379 --> 00:23:20.352 A 2026 sex analysis included 6,664 women, 35 percent of the pooled 00:23:20.395 --> 00:23:24.864 population. Women had a greater multimorbidity burden and were less likely to 00:23:24.906 --> 00:23:28.384 receive several commonly indicated CKM therapies at baseline. 00:23:28.874 --> 00:23:32.800 No evidence of treatment-effect heterogeneity by sex was found for the assessed 00:23:32.928 --> 00:23:38.152 finerenone outcomes. This supports attention to treatment access and equitable assessment; it 00:23:38.194 --> 00:23:41.323 does not establish a special female-only drug effect. 00:23:41.592 --> 00:23:45.646 For Angela, close the treatment discussion by listing the clinical problem, the 00:23:45.688 --> 00:23:49.955 option chosen or deferred, the reason, the safety plan and her own 00:23:50.040 --> 00:23:53.582 goal. A defensible decision may include a reason not to use a 00:23:53.582 --> 00:23:58.503 therapy. Educational success is appropriate selection and follow-through, not the number of 00:23:58.546 --> 00:24:01.042 prescriptions or adoption of a particular brand. 00:24:01.362 --> 00:24:05.192 Here is the decision. Angela reads that one trial improved symptoms and 00:24:05.235 --> 00:24:07.453 another reduced a composite event outcome. 00:24:07.667 --> 00:24:11.080 What should the clinician clarify? Pause here if you would like a 00:24:11.123 --> 00:24:13.836 moment to think it through. The best next step in this case 00:24:14.007 --> 00:24:18.871 is: Confirm each study’s population, endpoint and current product label before applying 00:24:18.999 --> 00:24:23.447 the result. This avoids converting different evidence into an unsupported drug ranking. 00:24:23.800 --> 00:24:28.877 The takeaway: Use heart failure evidence even without diabetes, distinguish symptom and 00:24:28.962 --> 00:24:32.226 event endpoints, and individualize obesity treatment. 00:24:32.504 --> 00:24:35.646 Compare each option with its own evidence and current label. 00:24:36.233 --> 00:24:39.327 Before we move on, let’s apply that reasoning in more detail. 00:24:39.689 --> 00:24:42.356 A treatment gap is a prompt to assess eligibility. 00:24:42.590 --> 00:24:50.825 A US registry study published in 2025 examined 759,915 patients at 191 00:24:50.910 --> 00:24:57.777 outpatient cardiovascular practices using records from July 2019 through June 2023. 00:24:58.012 --> 00:25:02.278 In the combined heart failure with mildly reduced ejection fraction/heart failure with 00:25:02.364 --> 00:25:07.803 preserved ejection fraction group, recorded S G L T 2-inhibitor prescribing reached 00:25:07.974 --> 00:25:10.171 12.8 percent in the final quarter. 00:25:10.577 --> 00:25:14.417 Female sex was associated with lower prescribing across the overall heart failure 00:25:14.502 --> 00:25:19.680 cohort. This is a historical observational finding, not a current 2026 rate 00:25:19.808 --> 00:25:22.769 or proof that every untreated patient should receive a medicine. 00:25:23.042 --> 00:25:27.266 Use the gap to improve the decision process: confirm the syndrome, assess 00:25:27.351 --> 00:25:32.386 clinical and product-specific eligibility, explain the expected benefit and limits, review safety 00:25:32.599 --> 00:25:35.064 and cost, and document the agreed plan. 00:25:35.353 --> 00:25:38.873 A balanced education program measures the quality of those decisions. 00:25:39.108 --> 00:25:41.967 It does not set a target for prescriptions of a particular product 00:25:42.223 --> 00:25:47.312 or assume that education alone removes insurance, laboratory or referral barriers. 00:25:47.665 --> 00:25:52.358 For heart failure, empagliflozin and dapagliflozin are each given at 10 milligrams 00:25:52.444 --> 00:25:55.953 daily when appropriate, but their renal-use instructions are not identical. 00:25:56.262 --> 00:25:59.888 Dapagliflozin initiation is not recommended below an E G F R of 00:25:59.974 --> 00:26:05.042 25 milliliters per minute per one point seven three square meters; empagliflozin 00:26:05.084 --> 00:26:08.540 heart failure studies enrolled patients down to 20 and did not enroll 00:26:08.626 --> 00:26:12.594 those below 20. Review the current complete label and clinical context rather 00:26:12.679 --> 00:26:14.504 than applying a single class cutoff. 00:26:14.793 --> 00:26:19.956 Assess volume status and correct depletion before initiation; the loop-diuretic plan may 00:26:19.999 --> 00:26:25.579 need adjustment. Review genital symptoms, serious urinary symptoms, poor intake and the 00:26:25.622 --> 00:26:28.834 possibility of ketoacidosis without marked hyperglycemia. 00:26:29.146 --> 00:26:32.687 Both labels direct withholding for at least three days before surgery or 00:26:32.730 --> 00:26:36.015 procedures associated with prolonged fasting, when possible. 00:26:36.357 --> 00:26:39.952 Restarting requires clinical stability and resumed oral intake. 00:26:40.219 --> 00:26:43.675 Give the patient an actionable instruction and a contact route rather than 00:26:43.718 --> 00:26:45.830 an unexplained list of adverse effects. 00:26:46.065 --> 00:26:48.731 Separate guidance, approval and the woman in front of you. 00:26:48.923 --> 00:26:51.153 Evidence evolves after a course is written. 00:26:51.463 --> 00:26:57.820 The 2026 European Society of Cardiology guideline adds contemporary European recommendations across 00:26:57.991 --> 00:27:02.823 ejection fraction categories and discusses obesity therapies in symptomatic heart failure. 00:27:03.089 --> 00:27:07.655 US indication, dosing and safety decisions still require the current US product 00:27:07.783 --> 00:27:12.348 label and applicable US guidance. A guideline recommendation and a regulatory indication 00:27:12.604 --> 00:27:17.409 answer different questions. In the STEP H F peff pooled sex analysis, 00:27:17.537 --> 00:27:22.571 health-status improvement with semaglutide was similar in women and men, despite greater 00:27:22.742 --> 00:27:27.158 weight reduction in women. A women-focused case therefore does not justify claiming 00:27:27.201 --> 00:27:30.142 a uniquely larger heart failure treatment effect in women. 00:27:30.438 --> 00:27:34.534 Explain the population studied and the outcome measured, and avoid turning a 00:27:34.577 --> 00:27:37.130 subgroup description into a superiority claim. 00:27:37.421 --> 00:27:41.858 Build an individualized plan that also addresses blood pressure, atrial fibrillation when 00:27:41.901 --> 00:27:47.545 present, kidney health, sleep-disordered breathing, physical function, nutrition and access. 00:27:47.984 --> 00:27:53.637 Diuretics treat congestion; disease-modifying treatment and comorbidity management have distinct purposes. 00:27:54.000 --> 00:27:56.688 Neither weight loss nor relief of edema is a reason to stop 00:27:56.773 --> 00:27:59.574 asking whether the complete heart failure plan is appropriate. 00:28:00.103 --> 00:28:03.516 For our last case, Teresa is going home with a changed treatment 00:28:03.559 --> 00:28:07.633 plan. Teresa is home after a hospitalization for worsening heart failure. 00:28:07.825 --> 00:28:10.125 Her discharge list includes medication changes. 00:28:10.419 --> 00:28:13.448 A cardiology visit is planned, but she does not know who will 00:28:13.491 --> 00:28:16.428 review her next blood test. Clinical context. 00:28:16.678 --> 00:28:21.851 Confirmed heart failure with preserved ejection fraction; left ventricular ejection fraction 55 00:28:21.851 --> 00:28:25.083 percent; chronic kidney disease and type 2 diabetes. 00:28:25.424 --> 00:28:29.204 At the stable follow-up. E G F R 42 milliliters per minute 00:28:29.460 --> 00:28:34.814 per one point seven three square meters; potassium 4.7 milliequivalents per liter. 00:28:35.118 --> 00:28:40.010 Current task. Reconcile therapy and assess eligibility and safety before adding a 00:28:40.052 --> 00:28:46.122 mineralocorticoid receptor antagonist. Coordination gap. Laboratory date and responsible result reviewer are 00:28:46.165 --> 00:28:49.116 not documented. Reconstruct what is happening at home. 00:28:49.379 --> 00:28:52.408 Ask Teresa to bring the medicines she is actually taking, or review 00:28:52.536 --> 00:28:54.285 them by a reliable remote method. 00:28:54.712 --> 00:28:59.405 Compare the hospital list, the outpatient record, pharmacy information when available and 00:28:59.491 --> 00:29:03.858 her account. Resolve duplicate therapies, stopped medicines that remain in the record 00:29:04.071 --> 00:29:06.119 and prescriptions that were never filled. 00:29:06.460 --> 00:29:10.258 Ask about supplements, salt substitutes and nonprescription agents as part of the 00:29:10.300 --> 00:29:13.686 safety review. Do not interpret a missed dose as lack of interest 00:29:13.814 --> 00:29:20.556 without asking why. Cost, transportation, language, vision, manual dexterity and unclear instructions 00:29:20.897 --> 00:29:24.585 may all affect the plan. If the medicine is unaffordable, record the 00:29:24.628 --> 00:29:26.719 barrier and the action needed to address it. 00:29:26.975 --> 00:29:30.686 A plan that depends on a nonexistent supply is not an implemented 00:29:30.772 --> 00:29:35.752 treatment. Review symptoms, volume status, blood pressure and the trajectory of kidney 00:29:35.794 --> 00:29:39.890 function. The decision to add treatment must consider stability and the existing 00:29:39.976 --> 00:29:44.479 regimen. This fictional stable follow-up is an opportunity to close the monitoring 00:29:44.522 --> 00:29:48.148 gap; it is not permission to initiate therapy in a patient with 00:29:48.191 --> 00:29:53.638 acute deterioration without reassessment. Use the heart-failure label, not a remembered kidney 00:29:53.680 --> 00:29:58.203 schedule. Finerenone’s current US labeling includes adults with heart failure and left 00:29:58.331 --> 00:30:00.991 ventricular ejection fraction of at least 40 percent. 00:30:01.303 --> 00:30:04.397 Baseline potassium and E G F R are required. 00:30:04.717 --> 00:30:09.952 Do not initiate when potassium is above 5.0 milliequivalents per liter; initiation 00:30:10.165 --> 00:30:13.578 below E G F R 25 milliliters per minute per one point 00:30:13.664 --> 00:30:15.882 seven three square meters is not recommended. 00:30:16.181 --> 00:30:19.936 Strong C Y P 3 A 4 inhibitors and adrenal insufficiency are 00:30:19.936 --> 00:30:24.133 contraindications. Review interactions and the entire regimen. 00:30:24.432 --> 00:30:28.229 For the heart failure indication, starting and target doses depend on baseline 00:30:28.357 --> 00:30:32.197 E G F R, with subsequent decisions guided by potassium and kidney 00:30:32.240 --> 00:30:36.396 function. At Teresa’s stated baseline E G F R of 42, the 00:30:36.439 --> 00:30:39.938 label’s starting dose is 10 milligrams daily and target is 20 milligrams 00:30:40.023 --> 00:30:43.320 daily, subject to subsequent laboratory results and tolerability. 00:30:43.673 --> 00:30:47.001 Do not replace the heart failure dosing table with the chronic kidney 00:30:47.044 --> 00:30:51.560 disease-with-diabetes table. The heart failure label calls for potassium and E G 00:30:51.603 --> 00:30:55.869 F R four weeks after initiation and four weeks after dose adjustment, 00:30:56.083 --> 00:30:59.936 then periodically. Clinical changes may require earlier assessment. 00:31:00.205 --> 00:31:04.002 Use the current label for exact hold, restart and adjustment rules. 00:31:04.215 --> 00:31:07.522 The course does not replace those tables or a clinician’s judgment. 00:31:07.842 --> 00:31:12.430 Here is the decision. Teresa’s potassium is 4.7 and E G F 00:31:12.430 --> 00:31:17.289 R 42. After other eligibility and interaction checks, what completes a finerenone 00:31:17.417 --> 00:31:20.446 initiation plan? Pause here if you would like a moment to think 00:31:20.532 --> 00:31:23.979 it through. The best next step in this case is: Use the 00:31:24.021 --> 00:31:29.952 heart failure dosing instructions, arrange four-week potassium/E G F R testing, and 00:31:29.995 --> 00:31:32.587 name the reviewer and patient-contact process. 00:31:33.003 --> 00:31:36.651 The dose, tests, owner and communication process belong together. 00:31:36.928 --> 00:31:38.720 A laboratory order needs an owner. 00:31:38.891 --> 00:31:41.237 'Repeat labs' is not a complete plan. 00:31:41.536 --> 00:31:45.236 Specify the tests, date, location and responsible reviewer. 00:31:45.523 --> 00:31:48.809 The reviewer needs a process for acting on abnormal values and contacting 00:31:48.979 --> 00:31:51.923 Teresa. The team also needs a way to detect a test that 00:31:51.966 --> 00:31:55.454 was not completed; a missing result is not a normal result. 00:31:56.031 --> 00:31:59.700 For this case, the plan could read: 'Basic metabolic panel at four 00:31:59.786 --> 00:32:03.541 weeks after initiation, with potassium and E G F R review by 00:32:03.583 --> 00:32:08.889 the prescribing clinician; earlier clinical assessment if symptoms or intercurrent illness warrant. 00:32:09.076 --> 00:32:13.001 Nurse care coordinator checks completion and contacts the prescriber for missing or 00:32:13.044 --> 00:32:18.226 abnormal results. Results and instructions communicated to Teresa and documented.' The local 00:32:18.397 --> 00:32:21.981 team must assign real names and workable escalation thresholds. 00:32:22.237 --> 00:32:25.010 Confirm that the testing site is reachable and the order can be 00:32:25.053 --> 00:32:28.679 used there. Give Teresa a short written summary of when to go 00:32:28.850 --> 00:32:32.330 and whom to call. With her permission, include a support person. 00:32:32.629 --> 00:32:35.999 If a dose changes, the laboratory date must change with it; otherwise 00:32:36.170 --> 00:32:39.234 the chart can appear complete while the relevant monitoring is missed. 00:32:39.567 --> 00:32:42.639 Record that the result was reviewed and the patient informed. 00:32:42.980 --> 00:32:46.009 Sending a message into a portal that Teresa does not use may 00:32:46.052 --> 00:32:49.542 not complete the loop. Ask which contact method works for her and 00:32:49.585 --> 00:32:52.636 follow the organization’s privacy and communication policies. 00:32:52.870 --> 00:32:55.366 Explain benefit and risk in the same conversation. 00:32:55.601 --> 00:32:58.989 Teresa asks, 'Will this medicine keep me out of the hospital?' A 00:32:59.032 --> 00:33:03.725 useful answer respects both evidence and uncertainty: 'In a large trial, this 00:33:03.811 --> 00:33:08.348 treatment reduced the combined rate of worsening heart-failure events and cardiovascular death. 00:33:08.619 --> 00:33:11.094 It cannot promise that you will never need hospital care. 00:33:11.307 --> 00:33:15.019 We also need to watch potassium and kidney function.' Use the relevant 00:33:15.062 --> 00:33:17.509 population and endpoint when explaining a result. 00:33:17.866 --> 00:33:22.218 FINEARTS H F included mildly reduced and preserved ejection fraction; it counted 00:33:22.260 --> 00:33:25.775 recurrent worsening-heart failure events as well as cardiovascular death. 00:33:26.090 --> 00:33:29.418 A rate ratio for total events is not an individual patient’s chance 00:33:29.546 --> 00:33:33.643 of avoiding every event. The trial’s lack of a significant cardiovascular-death result 00:33:33.856 --> 00:33:37.269 alone should not be hidden. Ask Teresa to explain why the blood 00:33:37.312 --> 00:33:40.361 test matters. If she says it is only to see whether the 00:33:40.403 --> 00:33:42.750 drug is working, clarify the safety purpose. 00:33:43.006 --> 00:33:46.057 Hyperkalemia may not announce itself with a clear symptom. 00:33:46.334 --> 00:33:49.264 Monitoring is part of the treatment, even when she feels well. 00:33:49.507 --> 00:33:52.408 Do not let the routine pathway absorb an emergency. 00:33:52.834 --> 00:33:56.674 Now change the vignette. Teresa calls with new breathlessness at rest and 00:33:56.717 --> 00:34:00.173 chest pressure. This is a different decision from arranging the next routine 00:34:00.216 --> 00:34:05.694 blood test. Arrange emergency assessment; in the United States, severe or potentially 00:34:05.950 --> 00:34:10.473 life-threatening symptoms warrant calling 911. Do not ask her to wait for 00:34:10.516 --> 00:34:13.789 the scheduled visit or simply repeat an outpatient laboratory test. 00:34:14.076 --> 00:34:18.043 For nonemergency worsening symptoms, the care plan should explain how to reach 00:34:18.129 --> 00:34:20.753 the clinical team and when same-day advice is needed. 00:34:21.073 --> 00:34:24.571 Any individualized weight or symptom action plan should be provided by the 00:34:24.614 --> 00:34:28.856 treating team. Do not invent a universal diuretic self-adjustment rule from this 00:34:28.899 --> 00:34:32.867 case. Use teach-back while she is stable: 'If you develop chest pressure 00:34:33.080 --> 00:34:36.087 and cannot catch your breath at rest, what will you do?' Then 00:34:36.130 --> 00:34:39.543 ask whom she contacts for a nonemergency concern and when her next 00:34:39.671 --> 00:34:43.213 test and visit occur. Correct the plan in plain language rather than 00:34:43.255 --> 00:34:45.721 testing whether she can repeat clinical terminology. 00:34:46.053 --> 00:34:48.080 Turn a handoff into a completed action. 00:34:48.400 --> 00:34:52.338 A referral, order or discharge document is the start of a handoff. 00:34:52.649 --> 00:34:57.129 A completed handoff identifies the receiving clinician, the question to resolve, the 00:34:57.172 --> 00:35:01.876 current medicines and doses, recent results, pending tasks and the next contact. 00:35:02.271 --> 00:35:05.684 If no appointment is available, someone needs to address that gap rather 00:35:05.812 --> 00:35:08.282 than leaving an open-ended instruction to follow up. 00:35:08.534 --> 00:35:12.800 Evidence from STRONG H F supports the value of structured, closely monitored 00:35:12.886 --> 00:35:16.171 care after acute heart failure, but the trial was not restricted to 00:35:16.214 --> 00:35:18.315 heart failure with preserved ejection fraction. 00:35:18.624 --> 00:35:22.507 Its exact titration approach should not be transplanted wholesale to every woman 00:35:22.678 --> 00:35:27.328 with preserved ejection fraction. The transferable lesson here is to design follow-up 00:35:27.414 --> 00:35:29.581 that actively checks treatment and safety. 00:35:29.957 --> 00:35:33.157 For Teresa, the final note should make four things easy to find: 00:35:33.370 --> 00:35:36.954 what changed, what must be monitored, who will act and when she 00:35:36.997 --> 00:35:40.137 will hear from the team. At the next contact, confirm the test 00:35:40.222 --> 00:35:43.486 happened, the result was reviewed and the instruction reached her. 00:35:43.891 --> 00:35:46.537 The clinical outcome is not an order in the system; it is 00:35:46.579 --> 00:35:49.108 a patient who knows and can complete the next step. 00:35:49.417 --> 00:35:52.404 Here is the decision. The four-week result is missing. 00:35:52.788 --> 00:35:55.048 Which response best closes the care gap? 00:35:55.541 --> 00:35:57.952 Pause here if you would like a moment to think it through. 00:35:58.229 --> 00:36:01.813 The best next step in this case is: Check whether testing occurred, 00:36:02.026 --> 00:36:06.334 resolve access barriers, arrange needed testing and ensure clinician review. 00:36:06.589 --> 00:36:09.767 The team needs to track completion as well as interpret results. 00:36:10.173 --> 00:36:14.028 The takeaway: Monitoring and coordination are treatment tasks. 00:36:14.341 --> 00:36:18.650 Pair every medication change with a test date, a responsible reviewer, a 00:36:18.693 --> 00:36:21.377 communication plan and clear symptom escalation. 00:36:21.957 --> 00:36:25.136 Before we move on, let’s apply that reasoning in more detail. 00:36:25.541 --> 00:36:28.124 A safety call that cannot wait for the next blood test. 00:36:28.361 --> 00:36:32.312 Consider a separate development in Teresa’s story: after starting an S G 00:36:32.312 --> 00:36:37.107 L T 2 inhibitor she develops vomiting, poor intake, abdominal discomfort and 00:36:37.150 --> 00:36:41.741 breathlessness. Her home glucose is 146 milligrams per deciliter. 00:36:41.997 --> 00:36:45.538 This value does not rule out ketoacidosis associated with S G L 00:36:45.538 --> 00:36:50.004 T 2 treatment. Temporarily stop the medicine and arrange urgent clinical assessment 00:36:50.089 --> 00:36:53.225 for ketoacidosis, dehydration and other acute illness. 00:36:53.545 --> 00:36:56.830 Do not use a routine follow-up appointment or reassurance about the glucose 00:36:56.916 --> 00:37:00.866 value as the response. For a stable finerenone heart failure candidate with 00:37:00.951 --> 00:37:05.261 E G F R 42 and potassium 4.7, the current label begins 00:37:05.431 --> 00:37:09.984 at 10 milligrams daily, after the remaining eligibility and interaction checks. 00:37:10.313 --> 00:37:13.982 The heart failure target associated with that baseline renal category is 20 00:37:14.110 --> 00:37:18.974 milligrams daily, if the follow-up potassium, kidney function and full dose-adjustment instructions 00:37:19.230 --> 00:37:22.792 support titration. A target is not an instruction to start at the 00:37:22.834 --> 00:37:26.376 target. For baseline E G F R at least 60, the heart 00:37:26.418 --> 00:37:28.903 failure starting and target doses differ again. 00:37:29.169 --> 00:37:34.844 Do not initiate finerenone with potassium above 5.0 milliequivalents per liter; initiation 00:37:35.058 --> 00:37:38.081 below E G F R 25 is not recommended. 00:37:38.416 --> 00:37:43.195 Check contraindications, including strong C Y P 3 A 4 inhibitors and 00:37:43.237 --> 00:37:48.517 adrenal insufficiency. Use the heart failure-specific table when laboratory values change. 00:37:48.847 --> 00:37:53.455 A newly prescribed interacting medicine, dehydration, falling blood pressure or an acute 00:37:53.540 --> 00:37:58.362 illness can make a previously appropriate plan unsafe and may require assessment 00:37:58.447 --> 00:38:02.184 before the scheduled four-week review. Close the visit by asking Teresa to 00:38:02.227 --> 00:38:05.384 show how she will follow the plan: which medicine she is taking, 00:38:05.640 --> 00:38:09.267 when and where testing will occur, who will contact her, and which 00:38:09.352 --> 00:38:13.677 symptoms need immediate help. If a laboratory appointment or medication cannot be 00:38:13.720 --> 00:38:16.920 obtained, make the barrier visible to the responsible team. 00:38:17.219 --> 00:38:19.508 The plan is incomplete until it is feasible. 00:38:20.083 --> 00:38:23.710 Before you go, bring the three cases back to one question: what 00:38:23.753 --> 00:38:25.353 will you do differently at the next visit? 00:38:25.587 --> 00:38:29.470 Explain the symptom, use the endpoint the study actually measured, and give 00:38:29.555 --> 00:38:33.725 every monitoring plan an owner. You’ll find the source references, transcript and 00:38:33.767 --> 00:38:37.948 clinical resources beside this episode. To record your answers and complete the 00:38:37.991 --> 00:38:41.362 learning activity, return to the activity page for the questions and brief 00:38:41.447 --> 00:38:44.798 evaluation. This has been HEART RESERVE Clinical Conversations. 00:38:45.054 --> 00:38:47.355 I’m Lisa Zahakos. Thank you for listening.