1 00:00:11,440 --> 00:00:13,640 Welcome to the Clinical Center Grand Rounds, 2 00:00:13,640 --> 00:00:17,440 a weekly series of educational lectures for physicians and 3 00:00:17,440 --> 00:00:20,080 health care professionals broadcast from the Clinical 4 00:00:20,080 --> 00:00:23,040 Center at the National Institutes of Health in 5 00:00:23,040 --> 00:00:24,840 Bethesda, MD. 6 00:00:24,840 --> 00:00:28,400 The NIH Clinical Center is the world's largest hospital totally 7 00:00:28,400 --> 00:00:32,080 dedicated to investigational research and leads the global 8 00:00:32,080 --> 00:00:35,040 effort in training today's investigators and discovering 9 00:00:35,040 --> 00:00:37,200 tomorrow's cures. 10 00:00:37,200 --> 00:00:46,240 Learn more by visiting us online at http://clinicalcenter.nih.gov 11 00:00:46,240 --> 00:00:48,640 TODAY I'M HONORED TO INTRODUCE 12 00:00:48,640 --> 00:00:52,560 OUR SPEAKER DR. VERONIQUE ROGER, 13 00:00:52,560 --> 00:00:55,160 A SENIOR INVESTIGATOR AND BRANCH 14 00:00:55,160 --> 00:01:00,680 CHIEF AT THE DIVISION OF 15 00:01:00,680 --> 00:01:03,000 INTRAMURAL RESEARCH FOR NHLBI, 16 00:01:03,000 --> 00:01:04,080 PROFESSOR OF MEDICINE AND 17 00:01:04,080 --> 00:01:06,320 EPIDEMIOLOGY AT THE MAYO CLINIC 18 00:01:06,320 --> 00:01:07,200 COLLEGE OF MEDICINE. 19 00:01:07,200 --> 00:01:09,560 DR. ROGER EARNEDDED A MEDICAL 20 00:01:09,560 --> 00:01:12,360 DEGREE FROM UNIVERSITY OF PARIS 21 00:01:12,360 --> 00:01:13,480 SORBONNE SCHOOL OF MEDICINE, 22 00:01:13,480 --> 00:01:14,920 MASTER'S AT THE UNIVERSITY OF 23 00:01:14,920 --> 00:01:16,440 MINNESOTA, IN PUBLIC HEALTH. 24 00:01:16,440 --> 00:01:19,160 AFTER TRAINING IN CARD RADIOLOGY 25 00:01:19,160 --> 00:01:21,680 AT THE MAYO -- CARDIOLOGY AT 26 00:01:21,680 --> 00:01:24,520 MAYO BECOME PROFESSOR OF 27 00:01:24,520 --> 00:01:26,000 MEDICINE IN 2002 AND 28 00:01:26,000 --> 00:01:27,480 EPIDEMIOLOGY IN 2006. 29 00:01:27,480 --> 00:01:30,000 AT THE MAYO, DR. ROGER SERVED IN 30 00:01:30,000 --> 00:01:31,560 VARIOUS LEADERSHIP POSITIONS 31 00:01:31,560 --> 00:01:32,840 INCLUDING AS CHAIR OF THE 32 00:01:32,840 --> 00:01:33,960 DEPARTMENT OF HEALTH SCIENCES 33 00:01:33,960 --> 00:01:36,200 RESEARCH, AS A MEMBER OF THE 34 00:01:36,200 --> 00:01:36,880 MAYO CLINIC'S BOARD OF 35 00:01:36,880 --> 00:01:41,240 GOVERNORS, AND BOARD OF 36 00:01:41,240 --> 00:01:41,520 TRUSTEES. 37 00:01:41,520 --> 00:01:46,840 SHE JOINED NHLBI AS A SENIOR 38 00:01:46,840 --> 00:01:48,920 INVESTIGATOR BRANCH CHIEF IN 39 00:01:48,920 --> 00:01:50,120 2021, RESEARCH FOCUSING ON 40 00:01:50,120 --> 00:01:51,880 EPIDEMIOLOGY OUTCOMES OF 41 00:01:51,880 --> 00:01:53,520 CARDIOVASCULAR DISEASES, AND HAS 42 00:01:53,520 --> 00:01:54,480 BEEN FUNDED BY THE NATIONAL 43 00:01:54,480 --> 00:01:56,280 INSTITUTES OF HEALTH FOR MORE 44 00:01:56,280 --> 00:01:57,720 THAN 20 YEARS. 45 00:01:57,720 --> 00:02:01,720 HER LABORATORY OF HEART DISEASE 46 00:02:01,720 --> 00:02:07,400 INVESTIGATES HEART FAILURE 47 00:02:07,400 --> 00:02:08,000 PHENOTYPES, CRITICAL TO 48 00:02:08,000 --> 00:02:12,440 CONTEMPORARY EPIDEMIOLOGY. 49 00:02:12,440 --> 00:02:15,840 THE GROUP'S GOAL TO DETECT 50 00:02:15,840 --> 00:02:17,920 MECHANISMS OF SYNDROME WITH 51 00:02:17,920 --> 00:02:19,560 AGING AND DIVERSE POPULATIONS. 52 00:02:19,560 --> 00:02:24,160 SHE'S AN INTERNATIONAL LEADER IN 53 00:02:24,160 --> 00:02:26,000 CARDIOLOGY, CHAIR OF THE 54 00:02:26,000 --> 00:02:28,520 EXECUTIVE COMMITTEE OF THE NHLBI 55 00:02:28,520 --> 00:02:31,320 CORONARY ARTERY DISEASE IN YOUNG 56 00:02:31,320 --> 00:02:33,560 ADULTS STUDY, AMERICAN HEART 57 00:02:33,560 --> 00:02:34,880 ASSOCIATION SCIENTIFIC 58 00:02:34,880 --> 00:02:40,440 PUBLISHING COMMITTEE STATISTICS 59 00:02:40,440 --> 00:02:42,640 TASKS FOR, BOARD OF SCIENTIFIC 60 00:02:42,640 --> 00:02:44,000 COUNSELOR COMMITTEE, REVIEWER 61 00:02:44,000 --> 00:02:45,360 FORE20 JOURNALS INCLUDING NEW 62 00:02:45,360 --> 00:02:49,000 ENGLAND JOURNAL OF MEDICINE, 63 00:02:49,000 --> 00:02:50,240 LANCET, CIRCULATION, JAMA, 64 00:02:50,240 --> 00:02:51,000 ABRIDGED MEDICAL JOURNAL. 65 00:02:51,000 --> 00:02:53,280 DR. ROGER HAS RECEIVED NUMEROUS 66 00:02:53,280 --> 00:02:55,360 SCIENTIFIC AND ACADEMIC AWARDS 67 00:02:55,360 --> 00:02:56,040 IN HONOR INCLUDING RECOGNITION 68 00:02:56,040 --> 00:03:01,160 AS DISTINGUISHED SCIENTIST OF 69 00:03:01,160 --> 00:03:02,560 AMERICAN HEART ASSOCIATION MAYO 70 00:03:02,560 --> 00:03:03,120 CLINIC INVESTIGATOR, ELECTED 71 00:03:03,120 --> 00:03:05,520 MEMBER OF THE ASSOCIATION OF 72 00:03:05,520 --> 00:03:06,920 AMERICAN PHYSICIANS. 73 00:03:06,920 --> 00:03:07,920 INTERNATIONALLY RECOGNIZED 74 00:03:07,920 --> 00:03:11,640 SUBJECT MATTER EXPERT IN CARDIAC 75 00:03:11,640 --> 00:03:12,400 DISEASE EPIDEMIOLOGY, AUTHORED 76 00:03:12,400 --> 00:03:16,000 OVER 400 ARTICLES AND BOOK 77 00:03:16,000 --> 00:03:20,400 CHAPTERS, AND WORK CITED OVER 78 00:03:20,400 --> 00:03:22,200 130,000 TIMES, H-INDEX OF 127. 79 00:03:22,200 --> 00:03:23,600 NOW, PLEASE WELCOME OUR SPEAKER 80 00:03:23,600 --> 00:03:27,440 DR. ROGER, FOR HER PRESENTATION, 81 00:03:27,440 --> 00:03:29,400 HEART FAILURE IN POPULATIONS 82 00:03:29,400 --> 00:03:33,560 FROM DESCRIPTIVE EPIDEMIOLOGY TO 83 00:03:33,560 --> 00:03:34,240 MOLECULAR TAXONOMY. 84 00:03:34,240 --> 00:03:38,720 >> THANK YOU, DR. BURKLOW, FOR 85 00:03:38,720 --> 00:03:39,480 THIS REALLY OVERLY KIND 86 00:03:39,480 --> 00:03:39,800 INTRODUCTION. 87 00:03:39,800 --> 00:03:42,880 I'M THE ONE WHO IS HONORED TO 88 00:03:42,880 --> 00:03:44,840 GIVE CLINICAL CENTER GRAND 89 00:03:44,840 --> 00:03:48,000 ROUNDS AND LOOK FORWARD TO OUR 90 00:03:48,000 --> 00:03:49,640 TIME TOGETHER FOCUSING ON 91 00:03:49,640 --> 00:03:50,760 EPIDEMIOLOGY AND CLINICAL 92 00:03:50,760 --> 00:03:53,120 CLASSIFICATION OF HEART FAILURE. 93 00:03:53,120 --> 00:03:56,080 SO FIRST NO 94 00:03:56,080 --> 00:03:58,920 FINANCIAL DISCLOSURE, NO 95 00:03:58,920 --> 00:04:01,560 UNAPPROVED OR OFF-LABEL DRUG 96 00:04:01,560 --> 00:04:01,880 STATEMENT. 97 00:04:01,880 --> 00:04:02,960 OBJECTIVES FOR OUR TIME TOGETHER 98 00:04:02,960 --> 00:04:03,520 TODAY IS TO DESCRIBE 99 00:04:03,520 --> 00:04:05,960 EPIDEMIOLOGY OF HEART FAILURE 100 00:04:05,960 --> 00:04:07,080 ACROSS POPULATIONS, RECOGNIZE 101 00:04:07,080 --> 00:04:09,640 LIMITATIONS OF THE CURRENT 102 00:04:09,640 --> 00:04:11,560 CLASSIFICATION, AND AT THE SAME 103 00:04:11,560 --> 00:04:14,080 TIME RECOGNIZE OPPORTUNITIES OF 104 00:04:14,080 --> 00:04:16,960 MOLECULAR METHODS TO PHENOTYPE 105 00:04:16,960 --> 00:04:18,480 HEART FAILURE. 106 00:04:18,480 --> 00:04:20,360 SO IT'S CUSTOMARY TO START WITH 107 00:04:20,360 --> 00:04:22,600 A DEFINITION AND THE ONE THAT IS 108 00:04:22,600 --> 00:04:24,200 MOST COMMONLY USED IS THE ONE 109 00:04:24,200 --> 00:04:27,440 PUT FORTH BY THE AMERICAN 110 00:04:27,440 --> 00:04:28,760 COLLEGE OF CARDIOLOGY, AMERICAN 111 00:04:28,760 --> 00:04:29,760 HEART ASSOCIATION, IN THEIR 112 00:04:29,760 --> 00:04:32,040 GUIDELINE FOR THE EVALUATION AND 113 00:04:32,040 --> 00:04:36,440 MANAGEMENT OF CHRONIC HEART 114 00:04:36,440 --> 00:04:36,760 FAILURE. 115 00:04:36,760 --> 00:04:38,400 THOSE GUIDELINES, HEART FAILURE 116 00:04:38,400 --> 00:04:40,360 IS A COMPLEX CLINICAL SYNDROME 117 00:04:40,360 --> 00:04:43,000 THAT CAN RESULT FROM ANY STRUCK 118 00:04:43,000 --> 00:04:43,960 THY OR FUNCTIONAL CARDIAC 119 00:04:43,960 --> 00:04:45,400 DISORDER THAT IMPAIRS THE 120 00:04:45,400 --> 00:04:48,160 ABILITY OF VENTRICLE TO FILL 121 00:04:48,160 --> 00:04:50,320 WITH OR EJECT BLOOD. 122 00:04:50,320 --> 00:04:51,960 THERE'S A COUPLE POINTS TO 123 00:04:51,960 --> 00:04:53,640 EXTRACT OUT OF THIS DEFINITION 124 00:04:53,640 --> 00:04:56,360 THAT SERVES AS THE FOUNDATION OF 125 00:04:56,360 --> 00:04:57,640 THE CONVERSATION THIS AFTERNOON. 126 00:04:57,640 --> 00:05:00,200 THE ACKNOWLEDGMENT BY THE TWO 127 00:05:00,200 --> 00:05:03,120 LEADING PROFESSIONAL SOCIETY AND 128 00:05:03,120 --> 00:05:04,520 CARDIOLOGY WORLD OF THE 129 00:05:04,520 --> 00:05:05,960 SYNDROMIC NATURE OF HEART 130 00:05:05,960 --> 00:05:07,480 FAILURE, IT'S NOT A DISEASE, 131 00:05:07,480 --> 00:05:09,680 IT'S A COLLECTION OF DISEASES OR 132 00:05:09,680 --> 00:05:10,880 A SYNDROME AND IT'S IMPORTANT TO 133 00:05:10,880 --> 00:05:12,880 KEEP THIS IN MIND AS WE TALK 134 00:05:12,880 --> 00:05:13,640 THROUGH THIS. 135 00:05:13,640 --> 00:05:15,880 THE SECOND PIECE IS THAT IT 136 00:05:15,880 --> 00:05:17,000 ACKNOWLEDGES THE COMPLEXITY OF 137 00:05:17,000 --> 00:05:19,840 THE HEART FAILURE SYNDROME WHICH 138 00:05:19,840 --> 00:05:21,520 AGAIN WE'LL DIVE DEEPER INTO 139 00:05:21,520 --> 00:05:23,920 THROUGHOUT THE TALK. 140 00:05:23,920 --> 00:05:26,520 FINALLY THIS DEFINITION HAS BEEN 141 00:05:26,520 --> 00:05:28,400 INSERTED VERBATIM OVER THE PAST 142 00:05:28,400 --> 00:05:30,120 20 YEARS OF THE LIFESPAN OF THE 143 00:05:30,120 --> 00:05:31,120 GUIDELINES SINCE 2005, SO THIS 144 00:05:31,120 --> 00:05:34,840 IS A BIT OF AN INDIRECT SIGN, IF 145 00:05:34,840 --> 00:05:36,920 YOU WILL, THAT OUR APPREHENSION, 146 00:05:36,920 --> 00:05:38,680 IF YOU WILL, HASN'T EVOLVED MUCH 147 00:05:38,680 --> 00:05:42,280 OVER THE PAST TWO SEC DECADES. 148 00:05:42,280 --> 00:05:43,480 THE INTENSE INTEREST ON HEART 149 00:05:43,480 --> 00:05:48,400 FAILURE AT LEAST IN THE 150 00:05:48,400 --> 00:05:52,120 EPIDEMIOLOGY COMMUNITY STEMS 151 00:05:52,120 --> 00:06:02,680 FROM A PIECE WRITTEN IN 1997, AT 152 00:06:03,040 --> 00:06:04,280 THE TIME DR. BRAUNWALD ANNOUNCED 153 00:06:04,280 --> 00:06:09,640 THESE TWO, HEART FATURE AND 154 00:06:09,640 --> 00:06:10,640 ATRIAL FIBRILLATION. 155 00:06:10,640 --> 00:06:11,840 HE WAS GROUNDING THIS 156 00:06:11,840 --> 00:06:18,800 OBSERVATION GOOD HEART FAILURE, 157 00:06:18,800 --> 00:06:20,080 ADMISSIONS CLIMBING STEADILY, 158 00:06:20,080 --> 00:06:21,480 STILL IS THE MOST SINGLE 159 00:06:21,480 --> 00:06:23,000 FREQUENT CAUSE OF 160 00:06:23,000 --> 00:06:23,760 HOSPITALIZATION IN PERSONS 65 161 00:06:23,760 --> 00:06:28,520 YEARS AND OLDER. 162 00:06:28,520 --> 00:06:29,680 KEEPINGHOSPITAL ADMISSION AS THE 163 00:06:29,680 --> 00:06:32,320 METRIC BY WHICH THE STATEMENT 164 00:06:32,320 --> 00:06:34,040 WAS MADE WHAT DO HOSPITAL 165 00:06:34,040 --> 00:06:35,480 ADMISSIONS LOOK LIKE IN THAT 166 00:06:35,480 --> 00:06:36,840 TIME PERIOD? 167 00:06:36,840 --> 00:06:41,480 AND THIS SLIDE IS PURPOSEFULLY 168 00:06:41,480 --> 00:06:42,160 DATED REPRESENTING HOSPITAL 169 00:06:42,160 --> 00:06:45,440 ADMISSIONS, DISCHARGE IN THIS 170 00:06:45,440 --> 00:06:48,040 CASE, FOR HEART FAILURE BETWEEN 171 00:06:48,040 --> 00:06:48,840 1979 AND 2005. 172 00:06:48,840 --> 00:06:52,760 AND WHAT YOU CAN SEE IN THE 173 00:06:52,760 --> 00:06:55,840 STATISTIC IS THAT INDEED THERE 174 00:06:55,840 --> 00:07:00,440 HAS BEEN A STEADY CLIMB, 175 00:07:00,440 --> 00:07:01,520 QUASI-EXPONENTIALAL, FOR WOMEN 176 00:07:01,520 --> 00:07:03,280 IN BLUE, MEN IN RED. 177 00:07:03,280 --> 00:07:05,080 WHEN YOU LOOK AT THIS CERTAINLY 178 00:07:05,080 --> 00:07:07,200 IT RAISES THE QUESTION OF AN 179 00:07:07,200 --> 00:07:07,560 EPIDEMIC. 180 00:07:07,560 --> 00:07:10,960 HOWEVER, WE NEED TO REMEMBER 181 00:07:10,960 --> 00:07:12,160 THAT THESE HOSPITAL DISCHARGES 182 00:07:12,160 --> 00:07:15,240 ARE AT THE EPISODE LEVEL, NOT 183 00:07:15,240 --> 00:07:16,080 THE PERSON LEVEL. 184 00:07:16,080 --> 00:07:18,240 SO THAT A PATIENT WHO IS 185 00:07:18,240 --> 00:07:19,600 HOSPITALIZED THREE TIMES IN TWO 186 00:07:19,600 --> 00:07:21,560 YEARS, WHICH IS FREQUENTLY THE 187 00:07:21,560 --> 00:07:23,040 CASE WITH HEART FAILURE, IS 188 00:07:23,040 --> 00:07:25,680 COUNTED THREE TIMES, NOT ONE 189 00:07:25,680 --> 00:07:26,040 TIME. 190 00:07:26,040 --> 00:07:27,600 SO THIS PARTICULAR METRIC CANNOT 191 00:07:27,600 --> 00:07:29,200 MEASURE THE INCIDENCE OF THE 192 00:07:29,200 --> 00:07:29,560 DISEASE. 193 00:07:29,560 --> 00:07:31,920 FURTHERMORE IT'S NOT VALIDATED. 194 00:07:31,920 --> 00:07:33,920 IT'S DERIVED FROM HOSPITAL 195 00:07:33,920 --> 00:07:36,560 CODING OF ADMISSIONS WHICH AS WE 196 00:07:36,560 --> 00:07:41,000 KNOW HAS BEEN AMPLY 197 00:07:41,000 --> 00:07:42,240 DEMONSTRATED, SHIFTED AS 198 00:07:42,240 --> 00:07:42,920 REIMBURSEMENT PRACTICES EVOLVED. 199 00:07:42,920 --> 00:07:45,800 THIS KIND OF DATA IS IN FACT AN 200 00:07:45,800 --> 00:07:48,800 INTERESTING QUESTION, IT POSES A 201 00:07:48,800 --> 00:07:50,760 QUESTION, HYPOTHESIS GENERATING, 202 00:07:50,760 --> 00:07:54,480 NOT HYPOTHESIS TESTING, BUT IT 203 00:07:54,480 --> 00:07:55,120 CHALLENGES EPIDEMIOLOGIST TO 204 00:07:55,120 --> 00:07:56,560 INVESTIGATE THE EPIDEMIC OF 205 00:07:56,560 --> 00:07:56,880 HEART FAILURE. 206 00:07:56,880 --> 00:07:59,200 HOW WE'RE GOING TO GO ABOUT THAT 207 00:07:59,200 --> 00:08:01,840 TO INVESTIGATE THE EPIDEMIC, 208 00:08:01,840 --> 00:08:02,920 THAT'S EPIDEMIOLOGY 101, WE NEED 209 00:08:02,920 --> 00:08:04,960 TO UNDERSTAND SOME KEY METRICS 210 00:08:04,960 --> 00:08:06,720 THAT PERTAIN TO HEART FAILURE. 211 00:08:06,720 --> 00:08:10,680 WE NEED TO BE ABLE TO MEASURE 212 00:08:10,680 --> 00:08:13,080 INCIDENCE AND MORTALITY RATE. 213 00:08:13,080 --> 00:08:21,640 THOSE RATES ARE MADE, INCLUDING 214 00:08:21,640 --> 00:08:23,040 NUMERATOR AND DENOMINATOR, THE 215 00:08:23,040 --> 00:08:24,040 PATIENT ADMITTED THREE TIMES 216 00:08:24,040 --> 00:08:25,800 WILL BE COUNTED ONCE DURING THE 217 00:08:25,800 --> 00:08:30,160 FIRST UP SIDE. 218 00:08:30,160 --> 00:08:30,440 EPISODE. 219 00:08:30,440 --> 00:08:40,480 WE NEED TO FIND CASES VALIDATE 220 00:08:40,480 --> 00:08:42,200 BY RIGOROUS DIAGNOSIS, WE NEED 221 00:08:42,200 --> 00:08:44,720 TO HAVE A DENOMINATOR, STUDY 222 00:08:44,720 --> 00:08:46,040 DEFINED POPULATION THAT ENABLES 223 00:08:46,040 --> 00:08:48,440 US TO CALCULATE THOSE RATES. 224 00:08:48,440 --> 00:08:49,880 WHEN WE START THINKING ABOUT 225 00:08:49,880 --> 00:08:52,480 CRITERIA, WHICH AGAIN ARE SIMPLE 226 00:08:52,480 --> 00:08:53,720 CONCEPTUALLY, IT TURNS OUT THEY 227 00:08:53,720 --> 00:08:55,800 ARE SELDOM MET. 228 00:08:55,800 --> 00:08:57,440 THERE IS NO NATIONAL 229 00:08:57,440 --> 00:08:59,040 CARDIOVASCULAR DISEASE 230 00:08:59,040 --> 00:09:04,320 SURVEILLANCE AS OPPOSED TO 231 00:09:04,320 --> 00:09:08,560 CANCER, FEW PROGRAMS CONDUCTED 232 00:09:08,560 --> 00:09:11,040 SURVEILLANCE, RISK IN COMMUNITY 233 00:09:11,040 --> 00:09:19,320 STUDIES, WORCESTER HEART ATTACK, 234 00:09:19,320 --> 00:09:20,600 FRAMINGHAM AND ROCHESTER, ALL 235 00:09:20,600 --> 00:09:21,360 FUNDED BY NHLBI EXTRAMURAL 236 00:09:21,360 --> 00:09:22,240 GRANTS OR CONTRACTS. 237 00:09:22,240 --> 00:09:24,120 WE KNOW WHAT TO DO, HOW DO WE GO 238 00:09:24,120 --> 00:09:25,200 ABOUT IT? 239 00:09:25,200 --> 00:09:28,400 WE NEED AGAIN TO GROUND OUR 240 00:09:28,400 --> 00:09:29,960 INVESTIGATION INTO RIGOROUS 241 00:09:29,960 --> 00:09:30,560 DIAGNOSTIC CRITERIA. 242 00:09:30,560 --> 00:09:34,720 FOR THAT WE AND OTHERS HAVE USED 243 00:09:34,720 --> 00:09:35,640 THE FRAMINGHAM CRITERIA 244 00:09:35,640 --> 00:09:38,120 SUMMARIZED ON THIS SLIDE, WE 245 00:09:38,120 --> 00:09:40,520 FIND POTENTIAL CASES AND WE 246 00:09:40,520 --> 00:09:43,040 APPLY THESE CRITERIA TO 247 00:09:43,040 --> 00:09:43,720 ASCERTAIN THE VALIDATED 248 00:09:43,720 --> 00:09:45,120 DIAGNOSIS OF HEART FAILURE TO 249 00:09:45,120 --> 00:09:46,000 THAT PARTICULAR CASE. 250 00:09:46,000 --> 00:09:47,520 IF YOU LOOK AT THESE CRITERIA, 251 00:09:47,520 --> 00:09:49,000 YOU CAN SEE THERE'S QUITE A FEW 252 00:09:49,000 --> 00:09:51,160 OF THEM. 253 00:09:51,160 --> 00:09:57,400 THEY ARE CATEGORIZED AS MAJOR OR 254 00:09:57,400 --> 00:10:05,480 MINOR. 255 00:10:05,480 --> 00:10:08,000 YOU CAN STILL IN MOST CASES 256 00:10:08,000 --> 00:10:09,680 CLASSIFY THE CASES OF HEART 257 00:10:09,680 --> 00:10:10,880 FAILURE. 258 00:10:10,880 --> 00:10:12,120 THE OTHER IMPORTANT THING TO 259 00:10:12,120 --> 00:10:14,560 UNDERSTAND BY LOOKING AT THE 260 00:10:14,560 --> 00:10:16,680 CRITERIA, THEY ONLY INCLUDE ONE 261 00:10:16,680 --> 00:10:20,160 IMAGE AING MODALITY, THE CHEST 262 00:10:20,160 --> 00:10:21,720 X-RAY, PRESENT IN THE ENTIRE 263 00:10:21,720 --> 00:10:23,440 TIME PERIOD FOR THIS WORK. 264 00:10:23,440 --> 00:10:29,000 IT'S NOT DEPENDENT ON ANY OTHER 265 00:10:29,000 --> 00:10:30,360 IMAGING TECHNIQUE, IN PARTICULAR 266 00:10:30,360 --> 00:10:31,760 NO CARDIAC IMAGING OTHER THAN 267 00:10:31,760 --> 00:10:35,400 THE SILHOUETTE IS PART OF THIS 268 00:10:35,400 --> 00:10:35,680 ASSESSMENT. 269 00:10:35,680 --> 00:10:38,240 LET'S START WORKING WITH THE 270 00:10:38,240 --> 00:10:38,640 FRAMINGHAM CRITERIA. 271 00:10:38,640 --> 00:10:42,560 WE'RE GOING TO START WITH THE 272 00:10:42,560 --> 00:10:49,120 STUDY ITSELF. 273 00:10:49,120 --> 00:10:54,120 THIS IS DAN LEVY'S PAPER, 274 00:10:54,120 --> 00:10:55,680 LOOKING AT FOUR TIME PERIODS 275 00:10:55,680 --> 00:10:58,600 1950 IN BLUE TO TURN OF THE 276 00:10:58,600 --> 00:11:01,440 CENTURY IN PURPLE. 277 00:11:01,440 --> 00:11:03,000 DIVIDING THE INCIDENCE RATES 278 00:11:03,000 --> 00:11:04,600 MEASURED IN MORE RECENT TIME 279 00:11:04,600 --> 00:11:06,600 PERIODS IN REFERENCE TO THE 280 00:11:06,600 --> 00:11:08,560 EARLIER TIME PERIOD IN BLUE. 281 00:11:08,560 --> 00:11:10,440 SO WHAT IS PLOTTED HERE IS THE 282 00:11:10,440 --> 00:11:12,040 RATIO OF THE MORE RECENT 283 00:11:12,040 --> 00:11:13,680 INCIDENCE RATES IN THESE TIME 284 00:11:13,680 --> 00:11:15,280 PERIODS, COMPARED TO THE MOST -- 285 00:11:15,280 --> 00:11:16,240 THE OLDEST ONE. 286 00:11:16,240 --> 00:11:18,720 WHAT YOU CAN SEE HERE SPEAKS FOR 287 00:11:18,720 --> 00:11:20,680 ITSELF GRAPHICALLY, YOU CAN SEE 288 00:11:20,680 --> 00:11:25,320 THAT IN MEN ON THE LEFT THE AGE 289 00:11:25,320 --> 00:11:26,160 ADJUSTED INCIDENCE OF HEART 290 00:11:26,160 --> 00:11:27,840 FAILURE HAS NOT CHANGED COMPARED 291 00:11:27,840 --> 00:11:29,560 TO EARLIER TIME PERIOD. 292 00:11:29,560 --> 00:11:32,880 AND IN WOMEN, THERE'S EVEN AN 293 00:11:32,880 --> 00:11:34,560 INDICATION OF A DECLINE. 294 00:11:34,560 --> 00:11:35,760 NOW, WHAT ABOUT ELSEWHERE? 295 00:11:35,760 --> 00:11:36,520 THIS IS FRAMINGHAM. 296 00:11:36,520 --> 00:11:46,720 WE DID THE EXACT SAME STUDY IN 297 00:11:46,720 --> 00:11:49,760 OLMSTED COUNTY, APPLIED 298 00:11:49,760 --> 00:11:50,320 FRAMINGHAM CRITERIA, STUDIED 299 00:11:50,320 --> 00:11:51,560 ANALOGOUS TIME PERIODS. 300 00:11:51,560 --> 00:11:53,160 IN THE SAME FORMAT YOU CAN SEE 301 00:11:53,160 --> 00:11:55,280 AGAIN IN MEN ON THE LEFT AND IN 302 00:11:55,280 --> 00:11:58,040 WOMEN ON THE RIGHT THERE HAS 303 00:11:58,040 --> 00:12:00,640 BEEN NO CHANGE IN THE INCIDENCE 304 00:12:00,640 --> 00:12:04,240 OF HEART FAILURE OVER TIME. 305 00:12:04,240 --> 00:12:06,360 WHEN YOU JUXTAPOSE THESE TWO 306 00:12:06,360 --> 00:12:09,040 STUDIES, YOU CAN CLEARLY SEE BY 307 00:12:09,040 --> 00:12:10,400 LOOKING AT THIS WITH 308 00:12:10,400 --> 00:12:12,440 EPIDEMIOLOGY METHODS, WE'RE 309 00:12:12,440 --> 00:12:14,640 GETTING A VERY DIFFERENT PICTURE 310 00:12:14,640 --> 00:12:16,600 THAN THE STEADY RAISE IN 311 00:12:16,600 --> 00:12:17,520 ADMISSIONS FOR HEART FAILURE 312 00:12:17,520 --> 00:12:21,440 THAT I SHOWED AT THE BEGINNING 313 00:12:21,440 --> 00:12:23,040 IN THE VITAL STATISTICS. 314 00:12:23,040 --> 00:12:24,840 WE'RE INTERESTED IN SEEING 315 00:12:24,840 --> 00:12:26,040 WHETHER THIS TREND CONTINUES, 316 00:12:26,040 --> 00:12:28,760 THE DATA I'VE SHOWN ARE OLD, 317 00:12:28,760 --> 00:12:29,960 TURN OF THE CENTURY. 318 00:12:29,960 --> 00:12:32,800 WE LOOKED AT THIS IN AN UPDATED 319 00:12:32,800 --> 00:12:33,480 STUDY THROUGH 2010. 320 00:12:33,480 --> 00:12:37,640 AND THIS WAS PUBLISHED BY MY 321 00:12:37,640 --> 00:12:39,360 COLLEAGUE DR. GERBER IN JAMA OF 322 00:12:39,360 --> 00:12:40,560 INTERNAL MEDICINE IN 2015. 323 00:12:40,560 --> 00:12:43,640 YOU CAN SEE ON THIS SLIDE WE'RE 324 00:12:43,640 --> 00:12:44,200 REPRESENTING INCIDENCE RATES 325 00:12:44,200 --> 00:12:45,520 OVER TIME, MEN ON THE LEFT, 326 00:12:45,520 --> 00:12:48,120 WOMEN ON THE LEFT, MEN ON THE 327 00:12:48,120 --> 00:12:50,360 RIGHT, AND IF I COULD DRAW YOUR 328 00:12:50,360 --> 00:12:53,200 ATTENTION TO THE TOP CURVE, IN 329 00:12:53,200 --> 00:12:55,480 BLACK, YOU CAN SEE THE INCIDENCE 330 00:12:55,480 --> 00:12:58,240 OF HEART FAILURE IN WOMEN IS 331 00:12:58,240 --> 00:13:04,800 GOING DOWN, UP TO A NADIR OF 332 00:13:04,800 --> 00:13:10,160 2007 WHERE IT FLATTENS, IN MEN 333 00:13:10,160 --> 00:13:11,160 NADIR DELAYED TO 2008. 334 00:13:11,160 --> 00:13:13,880 NO PICTURE OF A STEADY RISE IN 335 00:13:13,880 --> 00:13:15,600 INCIDENCE OF HEART FAILURE IN 336 00:13:15,600 --> 00:13:16,800 MOST RECENT YEARS. 337 00:13:16,800 --> 00:13:20,560 IN THIS PARTICULAR STUDY WE HAD 338 00:13:20,560 --> 00:13:23,280 INFORMATION ON THE EJECTION 339 00:13:23,280 --> 00:13:25,240 FRACTION MARKED BY ECHO 340 00:13:25,240 --> 00:13:26,560 CARDIOGRAPHY, I'LL GET BACK TO 341 00:13:26,560 --> 00:13:27,440 THAT LATER. 342 00:13:27,440 --> 00:13:30,160 WE'RE ALSO ABLE TO LOOK AT THE 343 00:13:30,160 --> 00:13:31,360 INCIDENCE OF HEART FAILURE 344 00:13:31,360 --> 00:13:32,880 ACCORDING TO THE EJECTION 345 00:13:32,880 --> 00:13:33,160 FRACTION. 346 00:13:33,160 --> 00:13:35,720 WHAT YOU CAN SEE IN THOSE 347 00:13:35,720 --> 00:13:37,160 COLORED CURVES, TURQUOISE ONE, 348 00:13:37,160 --> 00:13:39,120 AND ORANGE ONE, IS THAT THERE'S 349 00:13:39,120 --> 00:13:40,560 ROUGHLY THE SAME NUMBER OF 350 00:13:40,560 --> 00:13:44,600 PATIENTS GIVE OR TAKE A FEW WITH 351 00:13:44,600 --> 00:13:47,000 PRESERVED AND REDUCED EJECTION 352 00:13:47,000 --> 00:13:49,400 FRACTION, TRENDS ARE REASONABLY 353 00:13:49,400 --> 00:13:51,040 PARALLEL TO ONE ANOTHER. 354 00:13:51,040 --> 00:13:52,600 WHAT ABOUT IN DIFFERENT SETTINGS 355 00:13:52,600 --> 00:13:53,000 AND COUNTRIES? 356 00:13:53,000 --> 00:13:55,920 THIS IS A PAPER PUBLISHED IN 357 00:13:55,920 --> 00:13:59,920 "LANCET" IN 2018 PERTAINING TO 358 00:13:59,920 --> 00:14:00,080 U.K. 359 00:14:00,080 --> 00:14:01,680 VERY LARGE COHORT, MUCH LARGER 360 00:14:01,680 --> 00:14:04,880 THAN THAT WHAT DR. LEVY WORKED 361 00:14:04,880 --> 00:14:08,920 WITH AT FRAMINGHAM AND US IN 362 00:14:08,920 --> 00:14:10,640 OLMSTEAD COUNTY. 363 00:14:10,640 --> 00:14:12,160 LET'S WALK THROUGH THIS AND 364 00:14:12,160 --> 00:14:14,520 FOCUS ON PANEL A ON THE LEFT 365 00:14:14,520 --> 00:14:16,880 PART OF THE SLIDE. 366 00:14:16,880 --> 00:14:22,680 WHAT YOU CAN SEE HERE IS A 367 00:14:22,680 --> 00:14:24,000 SERIES OF HORIZONTAL 368 00:14:24,000 --> 00:14:24,680 REPRESENTING REPRESENTING 369 00:14:24,680 --> 00:14:25,440 STANDARDIZED INCIDENCE OF HEART 370 00:14:25,440 --> 00:14:28,600 FAILURE BY AGE SO THE VERTICAL 371 00:14:28,600 --> 00:14:31,120 COLUMN IN THE MIDDLE REPRESENTS 372 00:14:31,120 --> 00:14:33,440 AGE OF THE POPULATION FROM 15 TO 373 00:14:33,440 --> 00:14:37,280 19 ALL THE WAY TO 90, HORIZONTAL 374 00:14:37,280 --> 00:14:38,360 BARS REPRESENT INCIDENCE OF 375 00:14:38,360 --> 00:14:42,880 HEART FAILURE IN TWO TIME 376 00:14:42,880 --> 00:14:45,520 PERIODS, 2002 IN GRAY, AND 2014 377 00:14:45,520 --> 00:14:46,120 IN BLUE. 378 00:14:46,120 --> 00:14:48,320 WHAT YOU CAN SEE IF YOU JUST 379 00:14:48,320 --> 00:14:50,960 LOOK AT THE SITE OF THESE BLUE 380 00:14:50,960 --> 00:14:52,200 AND GRAY BARS, ON THE LEFT PART 381 00:14:52,200 --> 00:14:54,680 OF THE SLIDE YOU CAN SEE THEY 382 00:14:54,680 --> 00:14:55,600 ARE THE SAME. 383 00:14:55,600 --> 00:14:58,520 WHICH WOULD TELL YOU THAT THE 384 00:14:58,520 --> 00:14:59,920 INCIDENCE OF HEART FAILURE 385 00:14:59,920 --> 00:15:01,600 HASN'T CHANGED DURING THOSE TWO 386 00:15:01,600 --> 00:15:02,360 TIME PERIODS. 387 00:15:02,360 --> 00:15:05,040 AND THAT'S WHAT THE AUTHORS 388 00:15:05,040 --> 00:15:07,720 CONCLUDED. 389 00:15:07,720 --> 00:15:11,680 NOW, WHAT WHAT DO WE MEAN BY 390 00:15:11,680 --> 00:15:14,280 STANDARDIZED INCIDENCE? 391 00:15:14,280 --> 00:15:15,080 CALCULATING TO ELIMINATE IMPACT 392 00:15:15,080 --> 00:15:19,440 OF A CHANGING IN AGE OF 393 00:15:19,440 --> 00:15:21,280 POPULATION TO LOOK AT WHAT'S 394 00:15:21,280 --> 00:15:23,160 HAPPENING AS IF THE POPULATION 395 00:15:23,160 --> 00:15:24,240 HAD NOT AGED. 396 00:15:24,240 --> 00:15:26,200 BUT OF COURSE THE POPULATION OF 397 00:15:26,200 --> 00:15:29,040 THE U.K. HAS AGED DURING THIS 398 00:15:29,040 --> 00:15:30,160 TIME PERIOD. 399 00:15:30,160 --> 00:15:33,200 SO THE INVESTIGATORS ALSO LOOKED 400 00:15:33,200 --> 00:15:35,720 AT THE INCIDENCE WHICH THEY 401 00:15:35,720 --> 00:15:37,240 CALLED THE CRUDE INCIDENCE 402 00:15:37,240 --> 00:15:38,680 WITHOUT ELIMINATING EFFECT OF 403 00:15:38,680 --> 00:15:38,960 AGE. 404 00:15:38,960 --> 00:15:40,440 AND THAT'S ON THE RIGHT PART OF 405 00:15:40,440 --> 00:15:40,840 THE SLIDE. 406 00:15:40,840 --> 00:15:43,840 SO IF YOU LOOK ON THE RIGHT 407 00:15:43,840 --> 00:15:45,600 PANEL, PANEL B, YOU CAN LOOK 408 00:15:45,600 --> 00:15:47,000 AGAIN AT THE HEIGHT OR THE 409 00:15:47,000 --> 00:15:48,760 LENGTH I SHOULD SAY OF THE 410 00:15:48,760 --> 00:15:51,800 HORIZONTAL BARS AND YOU CAN SEE 411 00:15:51,800 --> 00:15:53,880 THIS TIME THE BLUE BARS 412 00:15:53,880 --> 00:15:55,560 REPRESENTING THE MOST RECENT 413 00:15:55,560 --> 00:15:57,520 NUMBERS OF INCIDENT CASES OF 414 00:15:57,520 --> 00:16:00,320 HEART FAILURE ARE QUITE A BIT 415 00:16:00,320 --> 00:16:02,320 HIGHER, PARTICULARLY IN THE 416 00:16:02,320 --> 00:16:04,440 VALLEY OF THAT SHAPE, IF YOU 417 00:16:04,440 --> 00:16:07,000 WILL, THAN THEY WERE IN 2014 418 00:16:07,000 --> 00:16:09,200 THAN IN 2010. 419 00:16:09,200 --> 00:16:11,040 MEANING THAT WHEN YOU DO NOT 420 00:16:11,040 --> 00:16:13,600 ELIMINATE THE EFFECT OF AGE, THE 421 00:16:13,600 --> 00:16:19,080 INCIDENCE OF HEART FAILURE IS 422 00:16:19,080 --> 00:16:20,400 INCREASING QUITE SIGNIFICANTLY 423 00:16:20,400 --> 00:16:21,680 IN THE UNITED KINGDOM OVER THAT 424 00:16:21,680 --> 00:16:22,920 TIME PERIOD. 425 00:16:22,920 --> 00:16:25,200 WHAT ABOUT OUTCOMES? 426 00:16:25,200 --> 00:16:30,680 WHAT HAPPENS ONCE THEY HAVE THE 427 00:16:30,680 --> 00:16:31,560 DIAGNOSIS? 428 00:16:31,560 --> 00:16:36,680 I'M JUST THAT POSING RESULTS IN 429 00:16:36,680 --> 00:16:38,800 MINNESOTA AND THE PAPER. 430 00:16:38,800 --> 00:16:41,040 LOOKING AT TWO KEY DETERMINANTS, 431 00:16:41,040 --> 00:16:44,760 MORTALITY AND HOSPITALIZATION, 432 00:16:44,760 --> 00:16:46,320 DIFFERENT DRIVERS BUT STILL THE 433 00:16:46,320 --> 00:16:49,160 TWO KEY OUTCOMES WE LOOK AT. 434 00:16:49,160 --> 00:16:50,800 STARTING WITH MORTALITY, YOU CAN 435 00:16:50,800 --> 00:16:52,200 SEE IN OUR EXPERIENCE ON THE 436 00:16:52,200 --> 00:16:56,720 LEFT PART OF THE SLIDE 54% OF 437 00:16:56,720 --> 00:17:01,000 THE DEATHS DUE TO 438 00:17:01,000 --> 00:17:02,200 NON-CARDIOVASCULAR CASES, 439 00:17:02,200 --> 00:17:03,160 NON-CARDIOVASCULAR CAUSES. 440 00:17:03,160 --> 00:17:06,000 WE HAVE A HEART DISEASE RELATED 441 00:17:06,000 --> 00:17:08,640 SYNDROME, BUT YET MORE THAN HALF 442 00:17:08,640 --> 00:17:11,480 OF THE PEOPLE DIE OF DEATHS NOT 443 00:17:11,480 --> 00:17:13,120 ATTRIBUTED TO CARDIOVASCULAR 444 00:17:13,120 --> 00:17:13,440 DISEASE. 445 00:17:13,440 --> 00:17:14,240 AND THEY DIE A LOT. 446 00:17:14,240 --> 00:17:18,600 AT THE END OF THE FIRST YEAR 20% 447 00:17:18,600 --> 00:17:21,240 ARE DEAD, AT THE END OF FIVE 448 00:17:21,240 --> 00:17:24,640 YEARS MORE THAN HALF ARE 449 00:17:24,640 --> 00:17:28,000 DECEASED, WORSE THAN STICKS 450 00:17:28,000 --> 00:17:30,640 STATISTICS FOR A LOT OF CANCERS, 451 00:17:30,640 --> 00:17:32,280 IN THE LAST DECADE THERE'S BEEN 452 00:17:32,280 --> 00:17:32,800 NO IMPROVEMENT. 453 00:17:32,800 --> 00:17:34,440 IF YOU NOW LOOK AT MORTALITY IN 454 00:17:34,440 --> 00:17:35,440 THE U.K. GOING TO THE RIGHT PART 455 00:17:35,440 --> 00:17:37,320 OF THE SLIDE YOU CAN SEE THE 456 00:17:37,320 --> 00:17:40,040 SAME MESSAGE, HALF OF THE DEATHS 457 00:17:40,040 --> 00:17:42,160 ARE NON-CARDIOVASCULAR RELATED. 458 00:17:42,160 --> 00:17:47,400 IMPROVEMENT HAS BEEN QUITE 459 00:17:47,400 --> 00:17:51,040 MARGINAL, FROM 32 TO 29%, AND 460 00:17:51,040 --> 00:17:53,520 RESULTS, ACTUAL NUMBERS FOR 461 00:17:53,520 --> 00:17:56,160 MORTALITY IN THE TIME PERIODS 462 00:17:56,160 --> 00:17:58,080 ARE COMMENSURATE IN THE U.K. TO 463 00:17:58,080 --> 00:17:59,320 SOUTHEASTERN MINNESOTA. 464 00:17:59,320 --> 00:18:01,080 AS FAR AS HOSPITALIZATIONS IT'S 465 00:18:01,080 --> 00:18:04,680 VERY MUCH THE SAME MESSAGE, MOST 466 00:18:04,680 --> 00:18:06,680 HOSPITALIZATIONS ARE RELATED TO 467 00:18:06,680 --> 00:18:07,880 NON-CARDIOVASCULAR CAUSES, AMONG 468 00:18:07,880 --> 00:18:09,400 PEOPLE LIVING WITH HEART 469 00:18:09,400 --> 00:18:10,760 FAILURE, PARTICULARLY STRIKING 470 00:18:10,760 --> 00:18:14,960 IN THE U.K., 73% ARE 471 00:18:14,960 --> 00:18:15,840 NON-CARDIOVASCULAR RELATED. 472 00:18:15,840 --> 00:18:16,600 HOSPITALIZATIONS HAVE NOT 473 00:18:16,600 --> 00:18:18,800 CHANGED OVER TIME IN 474 00:18:18,800 --> 00:18:19,280 SOUTHEASTERN MINNESOTA. 475 00:18:19,280 --> 00:18:21,520 THEY HAVE INCREASED OVER TIME IN 476 00:18:21,520 --> 00:18:23,400 THE UNITED KINGDOM. 477 00:18:23,400 --> 00:18:24,600 THESE PEOPLE DIE. 478 00:18:24,600 --> 00:18:25,760 WHILE THEY WERE ALIVE THEY ARE 479 00:18:25,760 --> 00:18:28,440 IN THE HOSPITAL A LOT, QUALITY 480 00:18:28,440 --> 00:18:31,400 OF LIFE IS SEVERELY IMPAIRED BY 481 00:18:31,400 --> 00:18:32,600 HEART FAILURE. 482 00:18:32,600 --> 00:18:34,480 THESE OUTCOMES HAVE NOT IMPROVED 483 00:18:34,480 --> 00:18:38,880 OVER TIME AND THEY REMAIN GRIM 484 00:18:38,880 --> 00:18:39,840 DESPITE MAJOR EFFORTS IN 485 00:18:39,840 --> 00:18:40,840 IMPROVING THEM OVER THE TIME 486 00:18:40,840 --> 00:18:43,200 PERIOD OF INTEREST IN THE TWO 487 00:18:43,200 --> 00:18:43,440 STUDIES. 488 00:18:43,440 --> 00:18:46,640 THINGS ARE NOT GOING WELL. 489 00:18:46,640 --> 00:18:52,600 AND THEY ARE NOT FORECASTED TO 490 00:18:52,600 --> 00:18:52,800 IMPROVE. 491 00:18:52,800 --> 00:18:53,440 THE AMERICAN HEART ASSOCIATION 492 00:18:53,440 --> 00:18:57,840 PUTS TOGETHER EVERY YEAR A 493 00:18:57,840 --> 00:18:59,040 MASSIVE COMPENDIUM OF 494 00:18:59,040 --> 00:19:00,120 STATISTICS, THIS IS THE MOST 495 00:19:00,120 --> 00:19:02,640 RECENT VERSION THAT JUST CAME 496 00:19:02,640 --> 00:19:03,080 OUT. 497 00:19:03,080 --> 00:19:07,120 AND THEY APPLY SOPHISTICATED 498 00:19:07,120 --> 00:19:08,440 MODELING, BASED ON CURRENT STATE 499 00:19:08,440 --> 00:19:11,040 TO IDENTIFY FUTURE STATE, FOR 500 00:19:11,040 --> 00:19:14,320 HEART FAILURE FORECASTING THAT 501 00:19:14,320 --> 00:19:17,360 WE WILL GO FROM 6.7 MILLION 502 00:19:17,360 --> 00:19:20,240 AMERICANS TO 8 MILLION IN 2030 503 00:19:20,240 --> 00:19:21,880 LIVING WITH HEART FAILURE AND 504 00:19:21,880 --> 00:19:22,840 POPULATION OF THE UNITED STATES 505 00:19:22,840 --> 00:19:25,280 AS A WHOLE PERCENTAGE OF THOSE 506 00:19:25,280 --> 00:19:27,440 LIVING WITH HEART FAILURE WILL 507 00:19:27,440 --> 00:19:30,840 INCREASE FROM 2.4% OF POPULATION 508 00:19:30,840 --> 00:19:33,040 TO 3%. 509 00:19:33,040 --> 00:19:35,040 SO THESE ARE STAGGERING NUMBERS, 510 00:19:35,040 --> 00:19:39,600 FORECASTING IS AS GRIM AS THE 511 00:19:39,600 --> 00:19:40,160 CURRENT OUTCOME. 512 00:19:40,160 --> 00:19:42,920 WHAT IS THE PICTURE OF THE HEART 513 00:19:42,920 --> 00:19:44,120 FAILURE EPIDEMIC? 514 00:19:44,120 --> 00:19:47,040 IT REFLECTS AS WE'VE SEEN AN 515 00:19:47,040 --> 00:19:48,360 INCREASING PREVALENCE OF A 516 00:19:48,360 --> 00:19:52,840 DISEASE IN AN AGING POPULATION. 517 00:19:52,840 --> 00:19:56,120 WE COULD OFFER TO YOU THIS 518 00:19:56,120 --> 00:19:58,840 GRAPHIC CARTOON OF THE PICTURE 519 00:19:58,840 --> 00:20:01,400 OF HEART FAILURE EPIDEMIC, 520 00:20:01,400 --> 00:20:03,600 REVOLVING DOOR OF RECURRENT 521 00:20:03,600 --> 00:20:07,840 HOSPITALIZATIONS IN AN AGING 522 00:20:07,840 --> 00:20:08,440 POPULATION. 523 00:20:08,440 --> 00:20:11,040 THAT'S A COMPELLING PICTURE. 524 00:20:11,040 --> 00:20:14,080 IT'S AN INCOMPLETE PICTURE. 525 00:20:14,080 --> 00:20:22,960 LET'S TRY TO DRAW DOWN INTO 526 00:20:22,960 --> 00:20:24,960 OTHER ASPECTS. 527 00:20:24,960 --> 00:20:28,080 IN THIS COHORT OF 4 MILLION 528 00:20:28,080 --> 00:20:31,800 INDIVIDUALS THEY HAD DATA, 529 00:20:31,800 --> 00:20:32,680 ECONOMIC STATUS, ANALYZED BY 530 00:20:32,680 --> 00:20:33,640 QUINTILES, REPRESENTED IN THIS 531 00:20:33,640 --> 00:20:33,840 PLOT. 532 00:20:33,840 --> 00:20:39,040 SO WHAT THEY WERE ABLE TO 533 00:20:39,040 --> 00:20:40,360 DEMONSTRATE VERY ELOQUENTLY WHEN 534 00:20:40,360 --> 00:20:45,280 YOU GO FROM THE LEAST DEPRIVED 535 00:20:45,280 --> 00:20:47,280 PEOPLE AT THE BOTTOM OF THE SET 536 00:20:47,280 --> 00:20:49,440 OF CURVES TO THE MOST DEPRIVED 537 00:20:49,440 --> 00:20:51,840 PEOPLE AT THE TOP OF THE FAMILY 538 00:20:51,840 --> 00:20:56,240 OF CURVES, YOU CAN SEE A GRADED 539 00:20:56,240 --> 00:20:58,320 INCREASE IN THE INCIDENCE OF 540 00:20:58,320 --> 00:20:59,720 HEART FAILURE IN THE POPULATION 541 00:20:59,720 --> 00:21:03,440 OF THE U.K. WHICH TELLS YOU THAT 542 00:21:03,440 --> 00:21:04,200 THE MORE SOCIOECONOMICKICALLY 543 00:21:04,200 --> 00:21:07,040 DEPRIVED YOU ARE, THE MORE 544 00:21:07,040 --> 00:21:09,120 LIKELY YOU ARE TO EXPERIENCE 545 00:21:09,120 --> 00:21:10,840 HEART FAILURE, TO GET HEART 546 00:21:10,840 --> 00:21:13,280 FAILURE AND HAVE TO LIVE WITH 547 00:21:13,280 --> 00:21:14,160 HEART FAILURE. 548 00:21:14,160 --> 00:21:18,120 THE SECOND POINT ON THIS PLOT, 549 00:21:18,120 --> 00:21:21,280 YOU CAN SEE OVERALL THE CURVES 550 00:21:21,280 --> 00:21:22,280 ARE PARALLEL, AND DESCRIBE 551 00:21:22,280 --> 00:21:24,560 NICELY THE EXACT SAME PATTERN OF 552 00:21:24,560 --> 00:21:27,880 THE INCIDENCE OF HEART FAILURE 553 00:21:27,880 --> 00:21:29,720 WE OBSERVED IN OLMSTEAD COUNTY 554 00:21:29,720 --> 00:21:33,000 WITH DECLINED FOLLOWED BY NADIR 555 00:21:33,000 --> 00:21:35,960 IN 2006-2007 AND PLATEAU OR EVEN 556 00:21:35,960 --> 00:21:37,440 ARGUABLY AN INCREASE. 557 00:21:37,440 --> 00:21:39,800 THAT'S ONE ADDITIONAL FACET 558 00:21:39,800 --> 00:21:41,200 WHICH IS CRITICALLY IMPORTANT, 559 00:21:41,200 --> 00:21:44,360 THE ASSOCIATION WITH SOCIAL 560 00:21:44,360 --> 00:21:46,040 DEPRIVATION AND HEART FAILURE. 561 00:21:46,040 --> 00:21:48,240 SECOND FACET I WANT TO SHOW YOU 562 00:21:48,240 --> 00:21:50,720 COMES FROM HERE, IN THE UNITED 563 00:21:50,720 --> 00:21:51,640 STATES. 564 00:21:51,640 --> 00:21:57,320 THESE ARE DATA FROM CDC WONDER, 565 00:21:57,320 --> 00:21:58,160 FROM THE CENTERS FOR DISEASE 566 00:21:58,160 --> 00:22:01,480 CONTROL, THAT REPRESENTS DEATH 567 00:22:01,480 --> 00:22:07,360 RATE RELATED TO HEART FAIL, YOU 568 00:22:07,360 --> 00:22:08,200 -- 569 00:22:08,200 --> 00:22:10,360 FAILURE IN THE UNITED STATES 570 00:22:10,360 --> 00:22:13,400 STRATIFIED BY AGE, BY SEX, AND 571 00:22:13,400 --> 00:22:14,720 BY RACE. 572 00:22:14,720 --> 00:22:15,600 LET'S WALK THROUGH THIS DATA. 573 00:22:15,600 --> 00:22:17,680 FIRST OF ALL LET'S TURN OUR 574 00:22:17,680 --> 00:22:20,400 ATTENTION TO THE LEFT PANEL, 575 00:22:20,400 --> 00:22:23,040 YOUNGER ADULTS BETWEEN AGE 35 576 00:22:23,040 --> 00:22:26,720 AND 64, YOU CAN SEE HERE THAT 577 00:22:26,720 --> 00:22:30,480 THE PLOT REALLY SPEAKS FOR 578 00:22:30,480 --> 00:22:32,880 ITSELF, BY ILLUSTRATING PROFOUND 579 00:22:32,880 --> 00:22:37,160 DISPARITIES IN DEATHS RELATED TO 580 00:22:37,160 --> 00:22:38,560 HEART FAILURE BY RACE, BLACK MEN 581 00:22:38,560 --> 00:22:41,400 IN BLUE AT THE TOP OF THE CURVE, 582 00:22:41,400 --> 00:22:44,280 BY SEX -- BLACK WOMEN IN ORANGE, 583 00:22:44,280 --> 00:22:46,880 RIGHT BELOW BLACK MEN, BUT ALSO 584 00:22:46,880 --> 00:22:49,080 BY SEX WITH GREATER BURDEN OF 585 00:22:49,080 --> 00:22:51,480 HEART FAILURE AMONG MEN, WITHIN 586 00:22:51,480 --> 00:22:51,680 RACE. 587 00:22:51,680 --> 00:22:55,200 AND WHAT IS IN ADDITION TO THESE 588 00:22:55,200 --> 00:22:58,920 FINDINGS WHICH ARE QUITE 589 00:22:58,920 --> 00:22:59,920 STRIKING, ADDITIONAL MAJOR 590 00:22:59,920 --> 00:23:01,320 CONCERN IS THE FACT THESE 591 00:23:01,320 --> 00:23:03,640 DISPARITIES ARE GETTING WORSE. 592 00:23:03,640 --> 00:23:05,920 IF YOU FOCUS YOUR ATTENTION ON 593 00:23:05,920 --> 00:23:08,680 THE BLACK MEN IN BLUE, AND WHITE 594 00:23:08,680 --> 00:23:09,760 MEN IN GRAY, YOU LOOK AT THE 595 00:23:09,760 --> 00:23:11,520 SEPARATION OF THE CURVES, YOU 596 00:23:11,520 --> 00:23:14,920 CAN SEE IN MOST RECENT YEARS THE 597 00:23:14,920 --> 00:23:17,240 SEPARATION IS INCREASING. 598 00:23:17,240 --> 00:23:19,080 SO WE'RE ACTUALLY LOSING GROUND 599 00:23:19,080 --> 00:23:21,200 IN A DISEASE THAT'S ALREADY 600 00:23:21,200 --> 00:23:21,960 AFFECTED BY PROFOUND DISPARITIES 601 00:23:21,960 --> 00:23:23,840 AND HAS VERY POOR OUTCOMES AS WE 602 00:23:23,840 --> 00:23:24,040 KNOW. 603 00:23:24,040 --> 00:23:25,760 WHEN WE GET TO THE OLDER ADULTS 604 00:23:25,760 --> 00:23:29,400 ON THE RIGHT PART OF THE SLIDE, 605 00:23:29,400 --> 00:23:33,080 65 TO 84, YOU CAN SEE 606 00:23:33,080 --> 00:23:35,320 DIFFERENCES GET BLUNTED, BUT 607 00:23:35,320 --> 00:23:37,520 MAJOR DISPARITIES STILL HAPPEN. 608 00:23:37,520 --> 00:23:40,760 SO HEART FAILURE IS A DISEASE 609 00:23:40,760 --> 00:23:41,400 CHARACTERIZED BY PROFOUND 610 00:23:41,400 --> 00:23:43,320 DISPARITIES, RACE, ALSO TO SOME 611 00:23:43,320 --> 00:23:45,960 EXTENT BY SEX, PARTICULARLY 612 00:23:45,960 --> 00:23:46,640 PROMINENT AMONG YOUNGER ADULTS 613 00:23:46,640 --> 00:23:49,320 AT THE PRIME OF THEIR LIVES. 614 00:23:49,320 --> 00:23:52,000 SO WHEN WE THINK ABOUT STUDYING 615 00:23:52,000 --> 00:23:52,840 HEART FAILURE EPIDEMIOLOGY AND 616 00:23:52,840 --> 00:24:00,400 THINK ABOUT MOVING IN MOLECULR 617 00:24:00,400 --> 00:24:03,240 FIELD IT'S IMPERATIVE TO INCLUDE 618 00:24:03,240 --> 00:24:05,400 STUDY OF DIVERSE RACIAL AND 619 00:24:05,400 --> 00:24:06,080 ETHNIC POPULATIONS. 620 00:24:06,080 --> 00:24:10,480 WE CANNOT AIN ORDER NOT -- 621 00:24:10,480 --> 00:24:14,040 CANNOT AFFORD NOT TO DO IT OR 622 00:24:14,040 --> 00:24:15,000 ELIMINATE THE POPULATION MOST 623 00:24:15,000 --> 00:24:16,480 AFFECTED BY THE DISEASE UNDER 624 00:24:16,480 --> 00:24:16,800 CONSIDERATION. 625 00:24:16,800 --> 00:24:19,760 I WOULD ENCOURAGE YOU TO TURN TO 626 00:24:19,760 --> 00:24:22,480 THIS BEAUTIFUL PIECE WRITTEN BY 627 00:24:22,480 --> 00:24:25,400 OUR COLLEAGUES FROM NHLBI AND 628 00:24:25,400 --> 00:24:27,400 COLLABORATORS, PUBLISHED IN 629 00:24:27,400 --> 00:24:28,720 CIRCULATION RESEARCH IN 2019, 630 00:24:28,720 --> 00:24:32,240 PROVIDES US WITH A CONCEPTUAL 631 00:24:32,240 --> 00:24:33,880 FRAMEWORK TO STUDY 632 00:24:33,880 --> 00:24:35,560 CARDIOVASCULAR DISEASE IN 633 00:24:35,560 --> 00:24:37,520 CONTEMPORARY TIMES, CALLING FOR 634 00:24:37,520 --> 00:24:40,800 STRATEGIES THAT DIRECTLY ADDRESS 635 00:24:40,800 --> 00:24:42,120 DIVERSITY AND INCLUSION GOING 636 00:24:42,120 --> 00:24:45,320 BEYOND RACE AND ETHNICITY TO 637 00:24:45,320 --> 00:24:54,800 EXPLORE CONSTRUCTS INCLUDING 638 00:24:54,800 --> 00:24:56,280 ANCESTRY MATCH ROLES, CULTURAL 639 00:24:56,280 --> 00:24:57,200 AND ENVIRONMENTAL DETERMINANTS 640 00:24:57,200 --> 00:24:57,800 OF HEALTH. 641 00:24:57,800 --> 00:24:59,000 YOU MIGHT SAY, YEAH, THAT'S 642 00:24:59,000 --> 00:25:01,080 GREAT BUT SOUNDS LIKE IT'S A 643 00:25:01,080 --> 00:25:01,360 LOT. 644 00:25:01,360 --> 00:25:02,400 I CANNOT BOIL THE OCEAN. 645 00:25:02,400 --> 00:25:04,240 I WOULD SUBMIT TO YOU THAT WE DO 646 00:25:04,240 --> 00:25:09,280 NOT HAVE A CHOICE BUT TO 647 00:25:09,280 --> 00:25:11,120 INTERNALIZE THIS ROAD MAP 648 00:25:11,120 --> 00:25:13,440 OPERATIONALIZING IT LITTLE BY 649 00:25:13,440 --> 00:25:19,320 LITTLE BUT BY BEING COGNIZANT F 650 00:25:19,320 --> 00:25:21,680 THE ENTIRE IMPACT. 651 00:25:21,680 --> 00:25:25,440 THE NATIONAL INSTITUTE OF 652 00:25:25,440 --> 00:25:26,880 MINORITY HEALTH HAS CREATED THAT 653 00:25:26,880 --> 00:25:31,240 ROAD MAP, PUBLISHED ON THEIR 654 00:25:31,240 --> 00:25:31,800 WEBSITE. 655 00:25:31,800 --> 00:25:33,680 DR. PEREZ-STABLE AND TEAM HAVE 656 00:25:33,680 --> 00:25:37,600 PROVIDED US WITH A GRID, WITH A 657 00:25:37,600 --> 00:25:39,360 PARTITIONING OF LEVELS OF 658 00:25:39,360 --> 00:25:48,280 INFLUENCE ON THE HORIZONTAL 659 00:25:48,280 --> 00:25:50,920 AXIS, AND IN EACH OF THE BOXES 660 00:25:50,920 --> 00:25:55,080 YOU CAN BEGIN TO ORGANIZE YOUR 661 00:25:55,080 --> 00:25:57,800 THINKING ABOUT THE INTERSECTION 662 00:25:57,800 --> 00:26:01,000 WITH LEVEL OF INFLUENCE AND 663 00:26:01,000 --> 00:26:01,440 DOMAIN OF INFLUENCE. 664 00:26:01,440 --> 00:26:02,320 FOR EXAMPLE, IF YOU'RE 665 00:26:02,320 --> 00:26:04,200 INTERESTED IN LOOKING AT THE 666 00:26:04,200 --> 00:26:05,520 INDIVIDUAL FOR A STUDY YOU'RE 667 00:26:05,520 --> 00:26:07,800 DOING AND WANT TO LOOK AT THE 668 00:26:07,800 --> 00:26:10,320 BIOLOGICAL COMPONENT YOU'LL 669 00:26:10,320 --> 00:26:13,160 START THINKING ABOUT BIOLOGICAL 670 00:26:13,160 --> 00:26:14,440 VULNERABILITY AND MOLECULAR 671 00:26:14,440 --> 00:26:15,640 MECHANISMS. 672 00:26:15,640 --> 00:26:17,080 SO YOU WILL BE COGNIZANT OF THE 673 00:26:17,080 --> 00:26:20,240 FACT THERE ARE OTHER DIMENSIONS 674 00:26:20,240 --> 00:26:21,360 THAT NEED TO BE CONSIDERED 675 00:26:21,360 --> 00:26:24,080 PERHAPS NOT IN YOUR RESEARCH IF 676 00:26:24,080 --> 00:26:25,520 YOU DON'T HAVE ALL THESE 677 00:26:25,520 --> 00:26:33,760 DIMENSIONS THOUGH WE NEED TO 678 00:26:33,760 --> 00:26:35,280 STRIVE TO COLLECT THEM, BUT 679 00:26:35,280 --> 00:26:38,440 APPLIED TO HEART 235EU8URE THIS 680 00:26:38,440 --> 00:26:44,240 IS THE WORK THAT SARAH, A 681 00:26:44,240 --> 00:26:44,880 MEDICAL RESEARCH SCHOLAR 682 00:26:44,880 --> 00:26:48,680 PROGRAM, SHE DID WHEN SHE WORKED 683 00:26:48,680 --> 00:26:51,120 WITH US DURING HER FIRST YEAR, 684 00:26:51,120 --> 00:26:52,680 CAME AND SAID I'M INTERESTED IN 685 00:26:52,680 --> 00:26:53,280 HEALTH DISPARITIES AND 686 00:26:53,280 --> 00:26:55,840 UNDERSTAND WHAT IT DOES WHEN 687 00:26:55,840 --> 00:27:00,720 IT'S COUPLED WITH RURALITY AND 688 00:27:00,720 --> 00:27:04,160 I'D LIKE TO APPLY NIMHD 689 00:27:04,160 --> 00:27:04,880 FRAMEWORK. 690 00:27:04,880 --> 00:27:06,000 LET'S BEGIN TO WORK, SARAH. 691 00:27:06,000 --> 00:27:09,680 WHEN WE APPLIED THIS TO HEART 692 00:27:09,680 --> 00:27:16,280 FAILURE WE STARTED TO THINK 693 00:27:16,280 --> 00:27:21,120 ABOUT DOMAINS THAT ARE GOING TO 694 00:27:21,120 --> 00:27:24,520 COME TO PLAY AND HOW CAN WE 695 00:27:24,520 --> 00:27:25,680 BUCKET CONSTRUCTS IN EACH 696 00:27:25,680 --> 00:27:36,120 CONCEPT SO WE CAN BEGIN TO 697 00:27:37,760 --> 00:27:39,280 SYSTEMATIZE ANALYTICAL APPROACH, 698 00:27:39,280 --> 00:27:41,920 YOU APPLY THE SAME REASONING TO 699 00:27:41,920 --> 00:27:42,360 OUTCOME. 700 00:27:42,360 --> 00:27:44,400 WE NEEDED TO FIND A COHORT IN 701 00:27:44,400 --> 00:27:47,560 WHICH WE COULD CAPTURE MAYBE NOT 702 00:27:47,560 --> 00:27:48,800 EVERYTHING HERE BUT A GOOD PART 703 00:27:48,800 --> 00:27:49,680 OF IT. 704 00:27:49,680 --> 00:27:52,960 SO FOR THAT WE TURNED TO THE 705 00:27:52,960 --> 00:27:55,560 SOUTHERN COMMUNITY COHORT STUDY, 706 00:27:55,560 --> 00:27:57,320 FUNDED BY NCI, ENROLLED VERY 707 00:27:57,320 --> 00:27:59,720 LARGE NUMBER OF PARTICIPANTS, 708 00:27:59,720 --> 00:28:03,240 MORE THAN 84,000, BETWEEN 2002 709 00:28:03,240 --> 00:28:05,640 AND 2009, AND INCLUDED 12 STATES 710 00:28:05,640 --> 00:28:07,080 IN THE SOUTHEASTERN UNITED 711 00:28:07,080 --> 00:28:09,680 STATES, AND IN THIS COHORT WHICH 712 00:28:09,680 --> 00:28:11,760 WAS AGAIN FUNDED BY NCI, THE 713 00:28:11,760 --> 00:28:14,200 FOCUS WAS ON CANCER AND CHRONIC 714 00:28:14,200 --> 00:28:19,360 DISEASES, AND THE COHORT WAS 715 00:28:19,360 --> 00:28:22,600 TRULY UNIQUE, ITS AIMED BY 716 00:28:22,600 --> 00:28:23,840 DESIGN AT PREFERENTIALLY 717 00:28:23,840 --> 00:28:25,040 RECRUITING LOW INCOME 718 00:28:25,040 --> 00:28:28,360 INDIVIDUALS WHO ARE RESOURCE 719 00:28:28,360 --> 00:28:30,960 LIMITED, BLACK POPULATIONS AS 720 00:28:30,960 --> 00:28:31,480 WELL. 721 00:28:31,480 --> 00:28:34,320 IT'S QUITE DISTINCT POPULATION 722 00:28:34,320 --> 00:28:37,120 COMPARED TO MAJORITY OF OTHER 723 00:28:37,120 --> 00:28:39,160 COHORTS WHICH LACK ENROLLMENT OF 724 00:28:39,160 --> 00:28:40,720 THESE PARTICULAR POPULATIONS OR 725 00:28:40,720 --> 00:28:44,320 GROUPS OR SOCIAL GROUPS, THERE 726 00:28:44,320 --> 00:28:46,080 BY PRECLUDING TO UNDERSTAND THE 727 00:28:46,080 --> 00:28:48,160 OUTCOMES IN RELATIONSHIP TO 728 00:28:48,160 --> 00:28:49,000 THESE EXPOSURES. 729 00:28:49,000 --> 00:28:51,000 IN ORDER TO ASCERTAIN HEART 730 00:28:51,000 --> 00:28:58,000 FAILURE WE NEEDED TO RELY ON CMS 731 00:28:58,000 --> 00:28:58,880 MEDICARE LINKAGE, LANDING WITH 732 00:28:58,880 --> 00:29:02,160 27,000 PEOPLE, A LITTLE OVER 733 00:29:02,160 --> 00:29:04,880 20,000 INDIVIDUALS FREE OF HEART 734 00:29:04,880 --> 00:29:07,600 FAILURE AT BASELINE WITH CMS 735 00:29:07,600 --> 00:29:08,920 LINKED HEART FAILURE EVENTS IN 736 00:29:08,920 --> 00:29:11,720 FOLLOW-UP WE COULD ANALYZE. 737 00:29:11,720 --> 00:29:14,640 SO WHAT SARAH REPORTED IN THIS 738 00:29:14,640 --> 00:29:18,560 PAPER IN JAMA CARDIOLOGY IN 739 00:29:18,560 --> 00:29:23,200 JANUARY WHAT SHE REPORTED IS 740 00:29:23,200 --> 00:29:27,000 COMPELLING POWERFUL RESULTS 741 00:29:27,000 --> 00:29:28,560 DEMONSTRATING THE 742 00:29:28,560 --> 00:29:31,920 INTERSECTIONALITY BETWEEN RACE, 743 00:29:31,920 --> 00:29:35,200 BETWEEN SEX, AND BETWEEN 744 00:29:35,200 --> 00:29:35,640 RURALITY. 745 00:29:35,640 --> 00:29:39,480 IN EPIDEMIOLOGY JARGON WE TALK 746 00:29:39,480 --> 00:29:41,880 ABOUT A THREE-WAY INTERACTION, 747 00:29:41,880 --> 00:29:44,160 RESULTS ARE PRESENTED HERE. 748 00:29:44,160 --> 00:29:47,920 WHAT SARAH FOUND IS THAT BLACK 749 00:29:47,920 --> 00:29:54,920 MEN WHO LIVE IN RURAL AREAS HAVE 750 00:29:54,920 --> 00:30:00,800 A 34% INCREASE OF INCIDENCE OF 751 00:30:00,800 --> 00:30:03,360 HEART FAILURE COMPARED TO THEIR 752 00:30:03,360 --> 00:30:08,360 FEMALE COUNTERPART AND WHITE 753 00:30:08,360 --> 00:30:08,920 COUNTERPART. 754 00:30:08,920 --> 00:30:10,120 THIS DEMONSTRATES WHEN IT COMES 755 00:30:10,120 --> 00:30:14,920 TO INCIDENCE OF HEART FAILURE, 756 00:30:14,920 --> 00:30:16,360 MEN AND WOMEN ARE NOT CREATED 757 00:30:16,360 --> 00:30:16,680 EQUAL. 758 00:30:16,680 --> 00:30:21,160 BLACK AND WHITE PERSONS ARE NOT 759 00:30:21,160 --> 00:30:22,160 CREATED EQUAL. 760 00:30:22,160 --> 00:30:24,560 AND RURAL AND URBAN RESIDENTS 761 00:30:24,560 --> 00:30:27,160 ARE NOT CREATED EQUAL OR DIDN'T 762 00:30:27,160 --> 00:30:27,760 HAVE EQUAL EXPERIENCE, THAT 763 00:30:27,760 --> 00:30:31,000 WOULD BE MORE CORRECT. 764 00:30:31,000 --> 00:30:34,000 SO THIS WAS AN IMPORTANT 765 00:30:34,000 --> 00:30:36,160 FINDING, NOT ONLY BECAUSE WE'RE 766 00:30:36,160 --> 00:30:39,240 ABLE TO STUDY A UNIQUE COHORT 767 00:30:39,240 --> 00:30:43,680 BUT ALSO BECAUSE THIS COHORT HAD 768 00:30:43,680 --> 00:30:48,960 A VERY RICH NUMBER OF OTHER 769 00:30:48,960 --> 00:30:50,400 CO-VARIANTS ASCERTAINED IN THIS 770 00:30:50,400 --> 00:30:51,720 DATA COLLECTION ENABLING US TO 771 00:30:51,720 --> 00:30:55,120 MAKE SURE THAT WHEN WE FOUND 772 00:30:55,120 --> 00:30:56,840 THIS LARGE INCIDENCE OF HEART 773 00:30:56,840 --> 00:30:59,040 FAILURE IT WAS NOT REFLECTING 774 00:30:59,040 --> 00:31:02,120 ANY OTHER CONFOUNDERS, ANY OTHER 775 00:31:02,120 --> 00:31:03,040 CHARACTERISTICS TRAVELING WITH 776 00:31:03,040 --> 00:31:03,960 HEART FAILURE, IF YOU WILL. 777 00:31:03,960 --> 00:31:05,480 BECAUSE OF THE RICHNESS OF DATA 778 00:31:05,480 --> 00:31:07,400 IN THE SOUTHERN COMMUNITY COHORT 779 00:31:07,400 --> 00:31:13,120 STUDY SHE WAS ABLE TO ADJUST 780 00:31:13,120 --> 00:31:13,800 INCLUDING FOR INCOME VARIABLES 781 00:31:13,800 --> 00:31:15,640 THAT MAP OUT TO SOCIAL 782 00:31:15,640 --> 00:31:16,760 DETERMINANTS, MARITAL STATUS AND 783 00:31:16,760 --> 00:31:20,680 RACE AND ETHNICITY, AS WELL AS 784 00:31:20,680 --> 00:31:23,240 PHYSICAL ACTIVITY AND SEDENTARY, 785 00:31:23,240 --> 00:31:25,520 SELDOM CAPTURED IN COHORTS, 786 00:31:25,520 --> 00:31:27,600 RESULTS ARE COMPELLING, SPEAK 787 00:31:27,600 --> 00:31:29,840 FOR INDEPENDENT IMPACT OF 788 00:31:29,840 --> 00:31:30,680 RURALITY AMONG BLACK MEN, AND 789 00:31:30,680 --> 00:31:32,840 WHAT IS THE USE OF THIS? 790 00:31:32,840 --> 00:31:37,680 WELL, CERTAINLY HAVING THIS DAA 791 00:31:37,680 --> 00:31:39,120 AVAILABLE CAN HELP US DESIGN 792 00:31:39,120 --> 00:31:40,960 INTERVENTIONS TO REDUCE BURDEN 793 00:31:40,960 --> 00:31:44,480 OF HEART FAILURE IN THIS 794 00:31:44,480 --> 00:31:47,080 POPULATION, BY SPECIFICALLY 795 00:31:47,080 --> 00:31:48,080 TAILORING INTERVENTIONS AIMING 796 00:31:48,080 --> 00:31:49,360 AT REDUCING THE BURDEN IN THE 797 00:31:49,360 --> 00:31:50,240 POPULATION THAT EXPERIENCES THE 798 00:31:50,240 --> 00:32:00,680 MOST, WHICH IS BLACK MEN. 799 00:32:03,520 --> 00:32:04,360 ANOTHER FACET, MULTI-MORBIDITY. 800 00:32:04,360 --> 00:32:06,520 A LOT HAS BEEN WRITTEN, THIS HAS 801 00:32:06,520 --> 00:32:07,600 BEEN THE SUBJECT OF INTENSE 802 00:32:07,600 --> 00:32:09,360 INTEREST, I WOULD SAY OVER THE 803 00:32:09,360 --> 00:32:09,720 PAST DECADE. 804 00:32:09,720 --> 00:32:12,320 I WANT TO WALK YOU THROUGH SOME 805 00:32:12,320 --> 00:32:14,280 RESULTS TO HELP US UNDERSTAND 806 00:32:14,280 --> 00:32:16,160 WHY THIS WILL INFORM OUR 807 00:32:16,160 --> 00:32:19,640 MOLECULAR STUDIES WHEN WE GET TO 808 00:32:19,640 --> 00:32:21,480 THEM. 809 00:32:21,480 --> 00:32:28,000 HERE MY COLLEAGUE ALANNA 810 00:32:28,000 --> 00:32:28,640 CHAMBERLAIN ENUMERATED 811 00:32:28,640 --> 00:32:31,000 STRATIFIED BY SEX WITH MEN ON 812 00:32:31,000 --> 00:32:35,120 THE LEFT, WOMEN ON THE RIGHT, 813 00:32:35,120 --> 00:32:36,400 PRESENTED BY EJECTION FRACTION 814 00:32:36,400 --> 00:32:38,920 GREATER THAN 50% IN DARK BARS, 815 00:32:38,920 --> 00:32:40,840 IN YELLOW BARS REDUCED. 816 00:32:40,840 --> 00:32:44,080 YOU CAN IGNORE THE EJECTION 817 00:32:44,080 --> 00:32:46,680 FRACTION PIECE FOR NOW AND 818 00:32:46,680 --> 00:32:50,080 EYEBALL THE BARS AND FROM THAT 819 00:32:50,080 --> 00:32:51,400 EXERCISE A FEW IMMEDIATE 820 00:32:51,400 --> 00:32:53,920 OBSERVATIONS THAT COME TO MIND. 821 00:32:53,920 --> 00:32:56,880 FIRST OF ALL COMORBIDITIES ARE 822 00:32:56,880 --> 00:32:58,200 EXCEEDINGLY PRESENT IN PEOPLE 823 00:32:58,200 --> 00:32:59,400 WITH HEART FAILURE, WHEN WE 824 00:32:59,400 --> 00:33:02,520 TOTALED ALL OF THEM WHAT WE 825 00:33:02,520 --> 00:33:04,960 FOUND IS THAT 79 OR 80% OF 826 00:33:04,960 --> 00:33:07,800 PERSONS WITH HEART FAILURE LIVED 827 00:33:07,800 --> 00:33:09,920 WITH TWO OR THREE COMORBID 828 00:33:09,920 --> 00:33:10,680 CONDITIONS, HEART FAILURE AND 829 00:33:10,680 --> 00:33:12,960 TWO OR THREE OTHER THINGS THAT 830 00:33:12,960 --> 00:33:14,960 TRAVELED WITH HEART FAILURE FOR 831 00:33:14,960 --> 00:33:20,520 THEM. 832 00:33:20,520 --> 00:33:21,600 WHAT WERE THESE THINGS? 833 00:33:21,600 --> 00:33:27,440 THERE'S A LOT OF CARDIOVASCULAR 834 00:33:27,440 --> 00:33:28,080 COMORBID CONDITIONS, 835 00:33:28,080 --> 00:33:29,040 HYPERLIPIDEMIA, ET CETERA, NO 836 00:33:29,040 --> 00:33:31,480 SURPRISE THERE, HEART FAILURE IS 837 00:33:31,480 --> 00:33:34,760 END RESULT OF MULTIPLE 838 00:33:34,760 --> 00:33:36,040 CONDITIONS, THEY STILL EXIST 839 00:33:36,040 --> 00:33:37,680 ONCE PATIENT DEVELOPS HEART 840 00:33:37,680 --> 00:33:40,400 FAILURE, WE KNOW HOW TO TREAT 841 00:33:40,400 --> 00:33:41,600 THEM, NOT INTERFERING WITH 842 00:33:41,600 --> 00:33:44,680 TREATMENT OR MANAGEMENT BUT ARE 843 00:33:44,680 --> 00:33:45,080 HIGHLY PREVALENT. 844 00:33:45,080 --> 00:33:47,120 CONTRAST THIS WHEN WE LOOK AT 845 00:33:47,120 --> 00:33:48,600 THE CONDITIONS ON THE FAR RIGHT 846 00:33:48,600 --> 00:33:54,440 OF THE TWO PANELS, WHICH INCLUDE 847 00:33:54,440 --> 00:34:03,040 DEMENTIA, SUBSTANCE ABUSE, 848 00:34:03,040 --> 00:34:04,400 SCHIZOPHRENIA AND OTHERS. 849 00:34:04,400 --> 00:34:06,880 IF PATIENTS ARE LIVING WITH 850 00:34:06,880 --> 00:34:14,120 DEMENTIA OR SUBSTANCE USE OR 851 00:34:14,120 --> 00:34:19,920 SCHIZOPHRENIA THIS WILL ENTIRE 852 00:34:19,920 --> 00:34:25,160 FEAR -- INTERFERE WITH THE 853 00:34:25,160 --> 00:34:25,440 MANAGEMENT. 854 00:34:25,440 --> 00:34:27,000 WE HAVE OTHER PHYSICAL 855 00:34:27,000 --> 00:34:29,400 CONDITIONS FROM ARTHRITIS TO 856 00:34:29,400 --> 00:34:31,040 DEPRESSION, KIDNEY DISEASE, A 857 00:34:31,040 --> 00:34:33,480 LOT WITH QUITE PRESENT AND WILL 858 00:34:33,480 --> 00:34:37,200 INTERFERE WITH VARYING DEGREE 859 00:34:37,200 --> 00:34:38,480 WITH MANAGEMENT OF THESE 860 00:34:38,480 --> 00:34:39,440 PATIENTS. 861 00:34:39,440 --> 00:34:43,440 NOW, WHEN YOU SEE DATA LIKE 862 00:34:43,440 --> 00:34:45,400 THIS, WHAT ELSE IS NEW? 863 00:34:45,400 --> 00:34:48,120 THESE PEOPLE ARE OLD, MEAN AGE 864 00:34:48,120 --> 00:34:50,200 76, THEY HAVE COMORBIDITY, 865 00:34:50,200 --> 00:34:53,040 WHAT'S SO SPECIFIC ABOUT HEART 866 00:34:53,040 --> 00:34:53,280 FAILURE? 867 00:34:53,280 --> 00:34:54,280 YOU NEED CONTROLS, PEOPLE 868 00:34:54,280 --> 00:34:57,000 MATCHED FOR AGE AND MATCHED FOR 869 00:34:57,000 --> 00:34:58,760 SEX, BUT THAT DON'T HAVE HEART 870 00:34:58,760 --> 00:35:01,240 FAILURE AND YOU NEED TO LOOK AT 871 00:35:01,240 --> 00:35:03,640 THE PREVALENCE OF COMORBIDITY IN 872 00:35:03,640 --> 00:35:08,240 THESE TWO GROUPS, THE CASES AND 873 00:35:08,240 --> 00:35:08,480 CONTROL. 874 00:35:08,480 --> 00:35:13,640 ALANA CHAMBERLAIN DID THIS IN 875 00:35:13,640 --> 00:35:18,640 THIS PAPER, AND WE HAD 3,000 876 00:35:18,640 --> 00:35:21,280 MATCHED CASES AND CONTROLS AND 877 00:35:21,280 --> 00:35:24,120 LOOKED AGAIN AT THIS SORT OF 878 00:35:24,120 --> 00:35:25,040 LIST OF COMORBIDITIES. 879 00:35:25,040 --> 00:35:28,720 WHAT YOU CAN SEE IS THAT CASES 880 00:35:28,720 --> 00:35:32,320 ARE THE SAME AS CONTROL, IF 881 00:35:32,320 --> 00:35:36,920 THOSE ODDS RATIOS REPRESENTED BY 882 00:35:36,920 --> 00:35:38,920 THE HORIZONTAL BARS CROSSED THE 883 00:35:38,920 --> 00:35:40,440 VERTICAL LINE OF ONE. 884 00:35:40,440 --> 00:35:42,720 YOU CAN SEE A LOT CROSS VERTICAL 885 00:35:42,720 --> 00:35:44,800 LINE OF ONE, ARTHRITIS, YES, 886 00:35:44,800 --> 00:35:46,080 PREVALENT BUT NOT MORE SO IN 887 00:35:46,080 --> 00:35:51,800 CASINGS -- CASES THAN CONTROLS. 888 00:35:51,800 --> 00:35:54,120 ASTHMA, CANCER IS LESS FREQUENT 889 00:35:54,120 --> 00:35:54,960 THAN HYPERLIPIDEMIA. 890 00:35:54,960 --> 00:35:56,840 TURN YOUR ATTENTION TO OTHER 891 00:35:56,840 --> 00:35:59,360 CONDITIONS, ON THE OTHER SIDE OF 892 00:35:59,360 --> 00:36:01,360 THE VERTICAL LINE OF ONE, 893 00:36:01,360 --> 00:36:03,080 MEANING THAT HAVING HEART 894 00:36:03,080 --> 00:36:05,600 FAILURE IS ASSOCIATED WITH A 895 00:36:05,600 --> 00:36:07,000 GREATER ODDS OF HAVING THESE 896 00:36:07,000 --> 00:36:08,200 COMORBID CONDITIONS. 897 00:36:08,200 --> 00:36:11,280 AT THE TOP WE SEE HYPERTENSION, 898 00:36:11,280 --> 00:36:13,840 KNEW IT WAS GOING TO BE 899 00:36:13,840 --> 00:36:15,720 PREVALENT, WE UNDERSTAND WHY 900 00:36:15,720 --> 00:36:18,720 BECAUSE IT'S PART OF THE CAUSAL 901 00:36:18,720 --> 00:36:18,960 PATHWAY. 902 00:36:18,960 --> 00:36:21,120 LET'S LOOK CLOSELY AT THESE. 903 00:36:21,120 --> 00:36:22,440 CHRONIC KIDNEY DISEASE, WE'LL 904 00:36:22,440 --> 00:36:26,440 GET BACK TO THAT WITH OUR 905 00:36:26,440 --> 00:36:37,000 MOLECULAR STUDIES, MUCH MORE -- 906 00:36:37,000 --> 00:36:40,040 GREATER ODDS RATIO. 907 00:36:40,040 --> 00:36:42,800 FOR DIABETES IT'S HIGH, 908 00:36:42,800 --> 00:36:43,760 SUBSTANCE ABUSE, THAT POPULATION 909 00:36:43,760 --> 00:36:44,760 PLAYING A KEY ROLE. 910 00:36:44,760 --> 00:36:47,280 THE OTHER THING THAT THIS SLIDE 911 00:36:47,280 --> 00:36:50,560 SHOWS IS CONCEPT WE CALL 912 00:36:50,560 --> 00:36:53,520 ATTRIBUTABLE RISK IN 913 00:36:53,520 --> 00:36:55,680 EPIDEMIOLOGY, AN APPEALING 914 00:36:55,680 --> 00:36:57,960 CONCEPT, BECAUSE IT TELLS YOU 915 00:36:57,960 --> 00:37:01,320 WHAT WOULD HAPPEN TO THE DISEASE 916 00:37:01,320 --> 00:37:03,080 UNDER CONSIDERATION, HERE HEART 917 00:37:03,080 --> 00:37:05,040 FAILURE, IF THE CONDITION THAT 918 00:37:05,040 --> 00:37:06,720 WE'RE LOOKING AT WAS ELIMINATED. 919 00:37:06,720 --> 00:37:10,040 AND SO FROM THIS WE CAN SEE THAT 920 00:37:10,040 --> 00:37:14,760 IF CHRONIC KIDNEY DISEASE DID 921 00:37:14,760 --> 00:37:17,040 NOT EXIST, BECAUSE THE RISK OF 922 00:37:17,040 --> 00:37:20,240 HEART FAILURE FOR KIDNEY DISEASE 923 00:37:20,240 --> 00:37:22,520 IS KEY PERCENT, IF CHRONIC 924 00:37:22,520 --> 00:37:24,160 KIDNEY DISEASE WAS ELIMINATED WE 925 00:37:24,160 --> 00:37:27,000 WOULD ELIMINATE 18% OF THE CASES 926 00:37:27,000 --> 00:37:29,280 OF HEART FAILURE. 927 00:37:29,280 --> 00:37:31,600 AND OF COURSE CORONARY DISEASE 928 00:37:31,600 --> 00:37:32,880 IF WE ELIMINATED CORONARY 929 00:37:32,880 --> 00:37:34,520 DISEASE ABOUT 30% OF CASES OF 930 00:37:34,520 --> 00:37:37,960 HEART FAILURE WOULD BE LIMIT IN 931 00:37:37,960 --> 00:37:38,760 AD. 932 00:37:38,760 --> 00:37:41,480 THIS CONSTRUCT ALLOWS US TO IN 933 00:37:41,480 --> 00:37:42,920 SOME CASES TARGET INTERVENTION 934 00:37:42,920 --> 00:37:44,440 WHERE WE WOULD GET BIGGEST BANG 935 00:37:44,440 --> 00:37:53,680 FOR THE BUCK IN TERMS OF 936 00:37:53,680 --> 00:37:57,600 ATTRIBUTABLE RISK. 937 00:37:57,600 --> 00:38:06,360 YOU CAN SEE EMERGE HEART FAILURE 938 00:38:06,360 --> 00:38:07,680 AROUND SYSTEMIC ENTITY, THERE'S 939 00:38:07,680 --> 00:38:09,960 ALSO IMPAIRMENT IN KIDNEY 940 00:38:09,960 --> 00:38:13,240 FUNCTION, IMPAIRMENT IN LUNG 941 00:38:13,240 --> 00:38:15,240 FUNCTION, COPD, CHRONIC KIDNEY 942 00:38:15,240 --> 00:38:18,320 DISEASE, AND SO IN SOME CASES 943 00:38:18,320 --> 00:38:19,280 IMPAIRMENT IN SKELETAL MUSCLE 944 00:38:19,280 --> 00:38:20,680 FUNCTION, THAT MAPS OUT TO 945 00:38:20,680 --> 00:38:22,880 CONCEPT OF FRAILTY WHICH I WON'T 946 00:38:22,880 --> 00:38:25,520 HAVE TIME TO TALK ABOUT BUT 947 00:38:25,520 --> 00:38:27,480 HIGHLY PREVALENT IN HEART 948 00:38:27,480 --> 00:38:27,720 FAILURE. 949 00:38:27,720 --> 00:38:30,080 KEEP IN MIND IT IS A SYSTEMIC 950 00:38:30,080 --> 00:38:31,880 CONDITION AS WE GO IT THROUGH 951 00:38:31,880 --> 00:38:33,720 THE REST OF THE TALK. 952 00:38:33,720 --> 00:38:35,160 DOES IT MATTER? 953 00:38:35,160 --> 00:38:37,320 DO COMORBID CONDITIONS PLAY A 954 00:38:37,320 --> 00:38:39,720 ROLE IN OUTCOME OF HEART 955 00:38:39,720 --> 00:38:40,040 FAILURE? 956 00:38:40,040 --> 00:38:42,320 OF COURSE, A SIGNIFICANT ROLE. 957 00:38:42,320 --> 00:38:45,760 IN THIS OTHER PEOPLE A COLLEAGUE 958 00:38:45,760 --> 00:38:47,520 AT MAYO LOOKED AT, LOOKING AT 959 00:38:47,520 --> 00:38:50,120 CONDITIONS CLASSIFIED AS I'VE 960 00:38:50,120 --> 00:38:51,560 SEASON IN CARDIOVASCULAR OTHER 961 00:38:51,560 --> 00:38:57,680 PHYSICAL AND MENTAL WHICH IS THE 962 00:38:57,680 --> 00:38:58,800 NEUROCOGNITIVE ENTITIES 963 00:38:58,800 --> 00:39:02,440 LOOKING AT TWO OUTCOMES, 964 00:39:02,440 --> 00:39:03,160 CARDIOVASCULAR CONDITIONS DON'T 965 00:39:03,160 --> 00:39:13,000 PLAY A ROLE OR HARDLY ANY LOCAL. 966 00:39:13,000 --> 00:39:15,120 WHEREAS IT'S VERY DIFFERENT FOR 967 00:39:15,120 --> 00:39:16,320 MENTAL CONDITIONS OR 968 00:39:16,320 --> 00:39:17,160 NEUROCOGNITIVE CONDITIONS, 30% 969 00:39:17,160 --> 00:39:20,240 INCREASE IN RISK OF DEATH, AND 970 00:39:20,240 --> 00:39:21,840 FOR OTHER PHYSICAL CONDITIONS 971 00:39:21,840 --> 00:39:26,160 WITH 26% INCREASE IN RISK OF 972 00:39:26,160 --> 00:39:27,120 HOSPITALIZATIONS. 973 00:39:27,120 --> 00:39:28,440 SO COMORBID CONDITIONS ARE 974 00:39:28,440 --> 00:39:30,640 PREVALENT, NOT ONLY CAUSAL, AS 975 00:39:30,640 --> 00:39:33,240 BEST WE CAN TELL FOR A LOT OF 976 00:39:33,240 --> 00:39:34,800 PROPORTION OF HEART FAILURE 977 00:39:34,800 --> 00:39:45,320 CASES, BUT ALSO ASSOCIATED WITH 978 00:39:47,000 --> 00:39:48,800 VERY ADVERSE OUTCOMES. 979 00:39:48,800 --> 00:39:51,000 NOW HEART FAILURE IN THE CLINIC, 980 00:39:51,000 --> 00:39:56,520 LET'S LOOK AT HOW IT IS 981 00:39:56,520 --> 00:39:59,760 CURRENTLY CLASSIFIED. 982 00:39:59,760 --> 00:40:01,880 THIS IS EXCERPT OF 2020 983 00:40:01,880 --> 00:40:04,880 GUIDELINES, AMERICAN HEART 984 00:40:04,880 --> 00:40:07,200 ASSOCIATION GUIDELINES, ALSO 985 00:40:07,200 --> 00:40:09,640 ENDORSED BY HEART FAILURE 986 00:40:09,640 --> 00:40:11,040 SOCIETY OF AMERICA THAT PROPOSE 987 00:40:11,040 --> 00:40:14,960 TO THE CLINICIANS, TO US, 988 00:40:14,960 --> 00:40:15,760 CLASSIFICATION OF HEART FAILURE. 989 00:40:15,760 --> 00:40:20,920 AND THESE ARE THE MOST RECENT 990 00:40:20,920 --> 00:40:23,600 GUIDELINES, AUTHORITATIVE BODY 991 00:40:23,600 --> 00:40:27,360 OF INDIVIDUALS, VERY AUGUST 992 00:40:27,360 --> 00:40:29,120 PANEL OF EXPERTS. 993 00:40:29,120 --> 00:40:32,120 WHEN WE SEE PATIENTS FIRST, THE 994 00:40:32,120 --> 00:40:36,640 FIRST VISIT, WE NEED TO GET AN 995 00:40:36,640 --> 00:40:37,640 IMAGING STUDY REPORTING ON THE 996 00:40:37,640 --> 00:40:40,880 SQUEEZING FUNCTION OF THE HEART 997 00:40:40,880 --> 00:40:44,520 MILLION, EJECTION FRACTION, OR 998 00:40:44,520 --> 00:40:45,280 PERCENTAGE OF BLOOD EJECTED OUT 999 00:40:45,280 --> 00:40:49,000 OF THE HEART AT EACH HEART BEAT, 1000 00:40:49,000 --> 00:40:59,560 NEVER 100%, NORMAL IS TYPICALLY 1001 00:41:02,760 --> 00:41:08,280 BETWEEN 50 AND SEVEN. 1002 00:41:08,280 --> 00:41:09,160 REDUCED, MID-RANGE, AND 1003 00:41:09,160 --> 00:41:14,720 PRESERVED GREATER OR EQUAL TO 1004 00:41:14,720 --> 00:41:15,000 50. 1005 00:41:15,000 --> 00:41:17,040 YOU SEE MRS. JONES TODAY, PUT 1006 00:41:17,040 --> 00:41:19,400 HER ON TREATMENT, ASK HER TO 1007 00:41:19,400 --> 00:41:23,480 COME BACK AND REEVALUATE HER, 1008 00:41:23,480 --> 00:41:25,680 AND REIMAGING DO A SECOND STUDY 1009 00:41:25,680 --> 00:41:34,440 AND ASSUMING THIS HAPPENS, THE 1010 00:41:34,440 --> 00:41:37,600 PATIENT COMES BACK AND GETS 1011 00:41:37,600 --> 00:41:39,600 SECOND IMAGING WE NEED TO GO 1012 00:41:39,600 --> 00:41:43,320 FROM THESE THREE CATEGORIES TO 1013 00:41:43,320 --> 00:41:44,280 NOW EIGHT CATEGORIES. 1014 00:41:44,280 --> 00:41:47,480 I WILL SPARE YOU FROM READING 1015 00:41:47,480 --> 00:41:49,560 ALL OF THESE CATEGORIES, BUT 1016 00:41:49,560 --> 00:41:54,160 SUFFICE TO SAY THAT THIS 1017 00:41:54,160 --> 00:41:56,360 RECLASSIFICATION EXERCISE IS 1018 00:41:56,360 --> 00:41:57,000 COMPLEX, AND CUMBERSOME, 1019 00:41:57,000 --> 00:41:58,880 REQUIRES THAT YOU WOULD GET THE 1020 00:41:58,880 --> 00:42:00,400 PATIENT TO COME BACK AND 1021 00:42:00,400 --> 00:42:02,120 OBVIOUSLY WOULD NEED A SECOND 1022 00:42:02,120 --> 00:42:04,000 IMAGING STUDY TO DO THAT. 1023 00:42:04,000 --> 00:42:06,760 SO BEFORE I MOVE ON TO THE NEXT 1024 00:42:06,760 --> 00:42:08,360 SLIDE I JUST WOULD LIKE TO ASK 1025 00:42:08,360 --> 00:42:12,080 ALL OF US HERE IN THIS 1026 00:42:12,080 --> 00:42:14,720 CONVERSATION TO HONESTLY ASK 1027 00:42:14,720 --> 00:42:16,000 OURSELVES TWO QUESTIONS. 1028 00:42:16,000 --> 00:42:18,240 FIRST, FOR THOSE WHO SEE 1029 00:42:18,240 --> 00:42:22,200 PATIENTS, WHICH IS MY CASE, I 1030 00:42:22,200 --> 00:42:24,280 ASK MYSELF HOW DO I USE THIS 1031 00:42:24,280 --> 00:42:26,880 EXACTLY IN MY PRACTICE? 1032 00:42:26,880 --> 00:42:29,280 HOW DO I MEMORIZE THIS? 1033 00:42:29,280 --> 00:42:31,400 AND HOW DO I APPLY IT? 1034 00:42:31,400 --> 00:42:36,000 AND FOR THOSE WHO DO CLINICAL 1035 00:42:36,000 --> 00:42:37,200 RESEARCH OR EPIDEMIOLOGY 1036 00:42:37,200 --> 00:42:38,400 STUDIES, LET'S ASK OURSELVES HOW 1037 00:42:38,400 --> 00:42:42,240 DO I USE THIS IN MY RESEARCH? 1038 00:42:42,240 --> 00:42:45,200 HOW DO I APPLY THESE VERY 1039 00:42:45,200 --> 00:42:46,000 DISTINCT AND DEFINITE THRESHOLDS 1040 00:42:46,000 --> 00:42:55,040 IN THE RESEARCH THAT I DO? 1041 00:42:55,040 --> 00:42:57,880 DOING SO WHILE BEING FAITHFUL TO 1042 00:42:57,880 --> 00:42:59,640 PROFESSIONAL GUIDELINES, IN THIS 1043 00:42:59,640 --> 00:43:02,360 PUBLICATION IN MARCH THE AUTHORS 1044 00:43:02,360 --> 00:43:05,680 PUBLISHED THE PROFESSIONAL 1045 00:43:05,680 --> 00:43:06,520 SOCIETY GUIDELINES ACROSS THE 1046 00:43:06,520 --> 00:43:08,720 CONTINENTS, IF YOU WILL, AND 1047 00:43:08,720 --> 00:43:09,720 ACROSS PROFESSIONAL SOCIETIES. 1048 00:43:09,720 --> 00:43:12,360 SO IF WE START AT THE BOTTOM WE 1049 00:43:12,360 --> 00:43:13,960 CAN SEE THE GUIDELINES I'VE 1050 00:43:13,960 --> 00:43:16,640 SHOWN YOU, AMERICAN COLLEGE OF 1051 00:43:16,640 --> 00:43:17,960 CARDIOLOGY, HEART ASSOCIATION, 1052 00:43:17,960 --> 00:43:18,400 CATEGORIES. 1053 00:43:18,400 --> 00:43:20,880 THIS DOES NOT INCLUDE 1054 00:43:20,880 --> 00:43:22,520 RECLASSIFICATION EXERCISE THAT 1055 00:43:22,520 --> 00:43:27,240 I'VE SHOWN BUT THIS IS ORIGINAL 1056 00:43:27,240 --> 00:43:29,040 ASSESSMENT WITH FOUR THRESHOLDS, 1057 00:43:29,040 --> 00:43:31,160 WITH GREEN, YELLOW, IN RED. 1058 00:43:31,160 --> 00:43:34,040 LET'S LOOK AT EUROPE, ACROSS THE 1059 00:43:34,040 --> 00:43:35,240 ATLANTIC OCEAN, EUROPEAN SOCIETY 1060 00:43:35,240 --> 00:43:38,640 GUIDELINES DON'T HAVE THE EXACT 1061 00:43:38,640 --> 00:43:39,720 SAME THRESHOLD. 1062 00:43:39,720 --> 00:43:40,920 IT'S NOT SO VERY DIFFERENT BUT 1063 00:43:40,920 --> 00:43:42,320 IT'S NOT THE SAME. 1064 00:43:42,320 --> 00:43:44,560 THAT'S THE NIGHTMARE OF THE 1065 00:43:44,560 --> 00:43:45,960 EPIDEMIOLOGIST, TWO CUT-POINTS 1066 00:43:45,960 --> 00:43:47,560 WE HAVE TO CONTEND WITH. 1067 00:43:47,560 --> 00:43:50,640 NOT TOO BAD ACROSS THOSE TWO. 1068 00:43:50,640 --> 00:43:56,560 BUT LET'S LOOK AT THE AMERICAN 1069 00:43:56,560 --> 00:43:57,240 SOCIETY OF ECHO CARDIOGRAPHY 1070 00:43:57,240 --> 00:43:59,000 WITH EUROPEAN SOCIETY OF IMAGING 1071 00:43:59,000 --> 00:43:59,960 AND YOU CAN SEE THE HEIGHT OF 1072 00:43:59,960 --> 00:44:01,480 THE RED BARS IS VERY DIFFERENT 1073 00:44:01,480 --> 00:44:03,240 THAN IN THESE TWO RED BARS, SAME 1074 00:44:03,240 --> 00:44:05,680 THING FOR THE YELLOW ONES, AND 1075 00:44:05,680 --> 00:44:08,280 GREEN ONES OF COURSE AS THE 1076 00:44:08,280 --> 00:44:10,560 REMAINDER, IF YOU WILL. 1077 00:44:10,560 --> 00:44:13,520 FINALLY THE BRITISH SOCIETY OF 1078 00:44:13,520 --> 00:44:14,720 ECHO CARDIOGRAPHY WITH OLD 1079 00:44:14,720 --> 00:44:17,280 GUIDELINES AND CAME UP WITH NEW 1080 00:44:17,280 --> 00:44:19,880 CUT-POINTS HAVE ALSO DIFFERENT 1081 00:44:19,880 --> 00:44:20,360 THRESHOLDS. 1082 00:44:20,360 --> 00:44:21,920 SO, THIS, IF YOU'RE THINKING 1083 00:44:21,920 --> 00:44:25,040 ABOUT EJECTION FRACTION AS A 1084 00:44:25,040 --> 00:44:27,120 RESEARCH TOOL, BECOMES 1085 00:44:27,120 --> 00:44:27,880 EPIDEMIOLOGIST NIGHTMARE BECAUSE 1086 00:44:27,880 --> 00:44:30,080 WE CAN REALLY AGREE THERE'S NO 1087 00:44:30,080 --> 00:44:31,720 AGREEMENT ACROSS PROFESSIONAL 1088 00:44:31,720 --> 00:44:33,680 SOCIETIES IN WHAT THRESHOLD TO 1089 00:44:33,680 --> 00:44:35,080 USE. 1090 00:44:35,080 --> 00:44:36,840 ANOTHER COMPONENT OF THE 1091 00:44:36,840 --> 00:44:40,480 EPIDEMIOLOGIST'S MIGHT NAIR -- 1092 00:44:40,480 --> 00:44:44,400 NIGHTMARE IS THE VARIABILITY. 1093 00:44:44,400 --> 00:44:45,840 THE EARLY DAYS, DIDN'T GET 1094 00:44:45,840 --> 00:44:47,200 SPOKEN ABOUT BUT NOW SURFACING. 1095 00:44:47,200 --> 00:44:52,080 IF YOU LOOK AT LITERATURE ON 1096 00:44:52,080 --> 00:44:54,520 THIS TOPIC YOU'LL FIND A FAIR 1097 00:44:54,520 --> 00:44:55,880 AMOUNT OF DATA. 1098 00:44:55,880 --> 00:45:04,280 THIS WAS PUBLISHED IN JAM A, 1099 00:45:04,280 --> 00:45:07,440 MEASURING EJECTION FRACTION IN 1100 00:45:07,440 --> 00:45:09,680 PEOPLE WITH HEART FAILURE, 1101 00:45:09,680 --> 00:45:11,520 DEEMED CANDIDATES FOR 1102 00:45:11,520 --> 00:45:14,280 INTERVENTIONS BY DIFFERENT 1103 00:45:14,280 --> 00:45:17,720 METHODS, ECHO CARDIOGRAPHY MOST 1104 00:45:17,720 --> 00:45:24,200 COMMONLY USED, NUCLEAR METHODS 1105 00:45:24,200 --> 00:45:25,520 AND MRI. 1106 00:45:25,520 --> 00:45:29,200 IT'S NOT EVEN REFLECTING ROUTINE 1107 00:45:29,200 --> 00:45:31,200 CLINICAL PRACTICES, IT'S 1108 00:45:31,200 --> 00:45:32,120 REFLECTING PRISTINE PRACTICE, 1109 00:45:32,120 --> 00:45:34,720 SUBSTANTIAL VARIATION IN THE 1110 00:45:34,720 --> 00:45:36,800 ORDER OF 10%, BETWEEN MODALITIES 1111 00:45:36,800 --> 00:45:38,240 IN EJECTION FRACTION 1112 00:45:38,240 --> 00:45:39,840 DETERMINATION. 1113 00:45:39,840 --> 00:45:44,000 SO I'M ASKING YOU THEREFORE ARE 1114 00:45:44,000 --> 00:45:44,760 THESE EIGHT CATEGORIES 1115 00:45:44,760 --> 00:45:46,160 EXCRUCIATING CLASSIFICATION 1116 00:45:46,160 --> 00:45:48,280 RECOMMENDED BY GUIDELINES REALLY 1117 00:45:48,280 --> 00:45:51,320 REALISTIC WHEN YOU'RE DEALING 1118 00:45:51,320 --> 00:45:53,440 WITH INSTRUMENT MUCH LESS 1119 00:45:53,440 --> 00:45:55,040 PRECISE THAN THE CUT-POINTS 1120 00:45:55,040 --> 00:45:56,120 PRE-DETERMINED, I'LL LET YOU 1121 00:45:56,120 --> 00:45:59,120 ANSWER THAT QUESTION ON YOUR OWN 1122 00:45:59,120 --> 00:46:04,400 IN YOUR OWN CONSCIENCE, I GUESS 1123 00:46:04,400 --> 00:46:06,480 WHAT CAN WE SUMMARIZE? 1124 00:46:06,480 --> 00:46:09,680 WE HAVE MULTIPLE AMPLE EVIDENCE 1125 00:46:09,680 --> 00:46:10,320 OF COMPLEXITY AND HETEROGENEITY 1126 00:46:10,320 --> 00:46:12,600 OF THE HEART FAILURE SYNDROME, 1127 00:46:12,600 --> 00:46:15,240 INCIDENCE IS NOT A MAJOR DRIVER, 1128 00:46:15,240 --> 00:46:16,320 IT'S STAGNATING OR ARGUABLY 1129 00:46:16,320 --> 00:46:17,200 GOING UP. 1130 00:46:17,200 --> 00:46:19,600 OUTCOMES ARE POOR AND 1131 00:46:19,600 --> 00:46:20,080 STAGNATING. 1132 00:46:20,080 --> 00:46:22,480 AND DISPARITIES ARE LARGE AND 1133 00:46:22,480 --> 00:46:23,280 INCREASING. 1134 00:46:23,280 --> 00:46:26,080 THERE'S A HIGH PREVALENCE OF 1135 00:46:26,080 --> 00:46:28,800 COMORBID CONDITION WITH A 1136 00:46:28,800 --> 00:46:30,760 SUGGESTION OF A MULTI-SYSTEM 1137 00:46:30,760 --> 00:46:33,680 COMPONENT TO HEART FAILURE AND 1138 00:46:33,680 --> 00:46:37,400 FINALLY CURRENT TAXONOMY IS 1139 00:46:37,400 --> 00:46:38,440 IMPRECISE AND NOT MECHANISTIC 1140 00:46:38,440 --> 00:46:41,960 AND WE NEED TO DO BETTER. 1141 00:46:41,960 --> 00:46:43,400 CLASSIFICATION BASED ON 1142 00:46:43,400 --> 00:46:44,920 MECHANISM RATHER THAN OUTDATED 1143 00:46:44,920 --> 00:46:47,000 IMPRECISE MEASUREMENTS WILL HAVE 1144 00:46:47,000 --> 00:46:49,640 PROFOUND IMPLICATIONS FOR THE 1145 00:46:49,640 --> 00:46:50,440 MANAGEMENT AND COST AND 1146 00:46:50,440 --> 00:46:51,920 WELL-BEING OF THE PATIENTS 1147 00:46:51,920 --> 00:46:54,120 LIVING WITH HEART FAILURE. 1148 00:46:54,120 --> 00:46:56,000 AND AS A MATTER OF FACT 2022 1149 00:46:56,000 --> 00:46:58,600 GUIDELINES, THE WITH UNDERSTOOD 1150 00:46:58,600 --> 00:47:01,320 THAT CAME UP WITH THE 1151 00:47:01,320 --> 00:47:02,120 CLASSIFICATION ACKNOWLEDGE THAT 1152 00:47:02,120 --> 00:47:05,880 WE NEED TO MOVE FORWARD WITH THE 1153 00:47:05,880 --> 00:47:08,360 APPLICATION OF ADVANCED 1154 00:47:08,360 --> 00:47:13,400 PRECISION MEDICINE TECHNIQUES TO 1155 00:47:13,400 --> 00:47:18,200 IMPROVE TAXONOMY OF HEART 1156 00:47:18,200 --> 00:47:18,840 FAILURE. 1157 00:47:18,840 --> 00:47:21,080 FIRST, LET'S NOT LOOK FOR ONE 1158 00:47:21,080 --> 00:47:24,960 UNIFYING DISEASES, THERE WILL BE 1159 00:47:24,960 --> 00:47:25,960 SEVERAL, EJECTION FRACTION BASED 1160 00:47:25,960 --> 00:47:26,840 CLASSIFICATION IS LIMITED. 1161 00:47:26,840 --> 00:47:30,080 WE NEED TO HAVE IN MIND, TO 1162 00:47:30,080 --> 00:47:31,960 COMPARE RESULTS TO WHAT WE SEE 1163 00:47:31,960 --> 00:47:33,680 WITH EJECTION FRACTION BUT 1164 00:47:33,680 --> 00:47:35,520 SHOULD NOT GUIDE THE WAY WE 1165 00:47:35,520 --> 00:47:40,600 APPROACH THE STUDY OF THESE 1166 00:47:40,600 --> 00:47:41,920 PATIENTS AS THE PRIMARY AXIS, IF 1167 00:47:41,920 --> 00:47:42,240 YOU WILL. 1168 00:47:42,240 --> 00:47:45,320 WE NEED TO THINK ABOUT 1169 00:47:45,320 --> 00:47:46,640 MULTI-SYSTEM INVOLVEMENT AND 1170 00:47:46,640 --> 00:47:48,200 MULTI-MORBIDITY, WE'LL USE SOME 1171 00:47:48,200 --> 00:47:49,040 IDENTIFIED GROUPS OF PATIENTS 1172 00:47:49,040 --> 00:47:51,360 WHO PRESENT WITH HEART FAILURE 1173 00:47:51,360 --> 00:47:54,200 SUCH AS CORONARY DISEASE, 1174 00:47:54,200 --> 00:47:55,840 DIABETES, RENAL DISEASE, OBESITY 1175 00:47:55,840 --> 00:47:59,080 TO GUIDE US AND IT IS IMPERATIVE 1176 00:47:59,080 --> 00:48:01,400 TO STUDY AND ENGAGE DIVERSE 1177 00:48:01,400 --> 00:48:01,680 POPULATIONS. 1178 00:48:01,680 --> 00:48:05,680 SO, WHAT ARE THE OMICS? 1179 00:48:05,680 --> 00:48:10,400 I WON'T TALK ABOUT GENOMICS OR 1180 00:48:10,400 --> 00:48:11,320 TRANSCRIPTOMICS, WE'VE ELECTED 1181 00:48:11,320 --> 00:48:19,280 TO FOCUS ON PROTEOMICS AND 1182 00:48:19,280 --> 00:48:19,760 METABOLOMICS. 1183 00:48:19,760 --> 00:48:21,480 THE QUESTIONS WE SET OUT TO 1184 00:48:21,480 --> 00:48:24,640 ANSWERS WERE IN THIS VERY EARLY 1185 00:48:24,640 --> 00:48:26,280 PHASE CAN MOLECULAR PHENOTYPING 1186 00:48:26,280 --> 00:48:27,840 IDENTIFY DIFFERENT PRESENTATIONS 1187 00:48:27,840 --> 00:48:29,800 OF HEART FAILURE? 1188 00:48:29,800 --> 00:48:31,240 ARE MOLECULAR PHENOTYPES 1189 00:48:31,240 --> 00:48:32,640 ASSOCIATED WITH MORTALITY? 1190 00:48:32,640 --> 00:48:34,400 AND IMPORTANTLY FOR THE 1191 00:48:34,400 --> 00:48:38,120 CLINICIAN, DO THEY GIVE US 1192 00:48:38,120 --> 00:48:43,800 INCREMENTAL INFORMATION OVER 1193 00:48:43,800 --> 00:48:45,360 WHAT WE ALREADY KNOW? 1194 00:48:45,360 --> 00:48:47,760 SO TO DO THAT WE'VE BEGUN 1195 00:48:47,760 --> 00:48:49,520 STUDIES, EARLY STUDIES, PILOT 1196 00:48:49,520 --> 00:48:51,480 STUDIES, IN WHAT WE REFER TO AS 1197 00:48:51,480 --> 00:48:56,280 LEGACY COHORT WHICH IS A COHORT 1198 00:48:56,280 --> 00:48:59,800 OF 1388 COMMUNITY RESIDENTS FROM 1199 00:48:59,800 --> 00:49:02,440 SOUTHEASTERN MINNESOTA, USING 1200 00:49:02,440 --> 00:49:05,560 COHORT ASSEMBLED YEARS AGO, 1201 00:49:05,560 --> 00:49:07,080 VALIDATED HEART FAILURE USING 1202 00:49:07,080 --> 00:49:08,680 FRAMINGHAM CRITERIA, COMMUNITY 1203 00:49:08,680 --> 00:49:10,280 COHORT AS EXPECTED 75 YEARS OLD, 1204 00:49:10,280 --> 00:49:13,480 GIVE OR TAKE A FEW YEARS, HALF 1205 00:49:13,480 --> 00:49:13,960 ARE WOMEN, REFLECTING 1206 00:49:13,960 --> 00:49:18,080 DEMOGRAPHICS OF THE STATE OF 1207 00:49:18,080 --> 00:49:22,200 MINNESOTA, 92% WHITE ANCESTRY, 1208 00:49:22,200 --> 00:49:24,080 EQUALLY DISTRIBUTED. 1209 00:49:24,080 --> 00:49:33,160 WE HAD DATA ALLOWING TO 1210 00:49:33,160 --> 00:49:34,600 ASCERTAIN COMORBIDITIES AND WE 1211 00:49:34,600 --> 00:49:38,760 CARRIED DEATH AS ENDPOINT. 1212 00:49:38,760 --> 00:49:46,880 DID TWO MULTIOMIC, ONE USING 1213 00:49:46,880 --> 00:49:49,280 SOMA LOGIC AND SPECTROSCOPY, 1214 00:49:49,280 --> 00:49:51,680 WITH MACHINE LEARNING AND 1215 00:49:51,680 --> 00:49:53,440 CONVENTIONAL STATISTICAL 1216 00:49:53,440 --> 00:49:53,760 TECHNIQUES. 1217 00:49:53,760 --> 00:49:54,560 PROTEOMEICS ARE NOT NEW. 1218 00:49:54,560 --> 00:49:59,000 THIS IS A COVER EVER A NATURE 1219 00:49:59,000 --> 00:50:02,680 ISSUE, 2003, DEDICATED TO 1220 00:50:02,680 --> 00:50:07,240 PROTEOMICS, IT'S BEEN 20 YEARS. 1221 00:50:07,240 --> 00:50:08,240 WE NOW HAVE HIGH-THROUGHPUT 1222 00:50:08,240 --> 00:50:11,080 ASSAYS TO ALLOW US TO MEASURE 1223 00:50:11,080 --> 00:50:12,680 PROTEOMICS SIGNATURES AND GET 1224 00:50:12,680 --> 00:50:17,480 PROTEOMIC SIGNATURES IN LARGE 1225 00:50:17,480 --> 00:50:19,160 COHORTS WITH ALMOST 1400 1226 00:50:19,160 --> 00:50:20,360 PATIENTS. 1227 00:50:20,360 --> 00:50:23,200 WE USED THE SOMALOGIC ASSAY, 1228 00:50:23,200 --> 00:50:28,560 MEASURING IN EXCESS OF 7,000 1229 00:50:28,560 --> 00:50:29,560 PROTEINS, AFFINITY ASSAY BASED 1230 00:50:29,560 --> 00:50:31,400 ON TECHNIQUES THAT BINDS TO THE 1231 00:50:31,400 --> 00:50:35,360 TARGET PROTEINS AND THEN SORT 1232 00:50:35,360 --> 00:50:40,920 OF -- THIS AFFINITY IS USED TOO 1233 00:50:40,920 --> 00:50:41,680 MEASURE RELATIVE CONCENTRATION 1234 00:50:41,680 --> 00:50:47,680 IN THE ASSAYS, USED IN 1235 00:50:47,680 --> 00:50:49,240 NEUROLOGICAL AND RELATIONSHIPS 1236 00:50:49,240 --> 00:50:50,400 AND CARDIOVASCULAR DISEASES. 1237 00:50:50,400 --> 00:50:52,880 A POSTDOC WORKING IN THE LAB HAS 1238 00:50:52,880 --> 00:50:54,720 CONCENTRATED A LOT OF HIS WORK, 1239 00:50:54,720 --> 00:50:57,000 MAYBE ALL HIS WORK, ON 1240 00:50:57,000 --> 00:50:58,680 PROTEOMICS IN THE COMMUNITY 1241 00:50:58,680 --> 00:51:00,840 COHORT, LEGACY COHORT I 1242 00:51:00,840 --> 00:51:04,600 DESCRIBED, HERE THIS VOLCANO 1243 00:51:04,600 --> 00:51:06,720 PLOT REPRESENTS ASSOCIATION 1244 00:51:06,720 --> 00:51:09,840 BETWEEN THE 7,000 PROTEINS WITH 1245 00:51:09,840 --> 00:51:12,120 MORTALITY IN THIS COHORT. 1246 00:51:12,120 --> 00:51:15,760 AND BELOW THE DOTTED LINE IN THE 1247 00:51:15,760 --> 00:51:18,160 GRAY ARE ALL THE PROTEINS NOT 1248 00:51:18,160 --> 00:51:19,760 ASSOCIATED WITH MORTALITY. 1249 00:51:19,760 --> 00:51:21,000 WE STOPPED CONSIDERING THEM. 1250 00:51:21,000 --> 00:51:24,600 WHAT WE DID CONSIDER IN THE 1251 00:51:24,600 --> 00:51:26,560 ANALYSIS ARE THE 447 PROTEINS 1252 00:51:26,560 --> 00:51:28,680 THAT ARE ABOVE THE LINE, IN 1253 00:51:28,680 --> 00:51:31,280 BLUE, WHICH IS PROTECTIVE 1254 00:51:31,280 --> 00:51:32,280 AGAINST MORTALITY, NEGATIVE 1255 00:51:32,280 --> 00:51:34,440 ASSOCIATION PROTECTIVE AGAINST 1256 00:51:34,440 --> 00:51:36,200 DEATH OR IN RED POSITIVE, 1257 00:51:36,200 --> 00:51:38,880 MEANING EXCESS RISK OF DEATH. 1258 00:51:38,880 --> 00:51:42,800 WE LANDED WITH 447 PROTEINS THAT 1259 00:51:42,800 --> 00:51:44,000 CARRY ASSOCIATION WITH DEATH, 1260 00:51:44,000 --> 00:51:47,640 AFTER CORRECTION FOR MULTIPLE 1261 00:51:47,640 --> 00:51:48,160 COMPARISONS BECAUSE WE'RE 1262 00:51:48,160 --> 00:51:49,680 TESTING VERY LARGE NUMBER OF 1263 00:51:49,680 --> 00:51:50,680 HIGH POTENTIAL APPROACHES THESE 1264 00:51:50,680 --> 00:51:53,960 WITH 7,000 PROTEINS SO WE'VE GOT 1265 00:51:53,960 --> 00:51:56,120 TO ACCOUNT FOR THAT ANALYTICS. 1266 00:51:56,120 --> 00:51:58,440 ONCE WE HAVE 47 PROTEINS APPLIED 1267 00:51:58,440 --> 00:51:59,440 MACHINE LEARNING AND CLUSTERING 1268 00:51:59,440 --> 00:52:02,400 ANALYSIS TO SEE IF WE COULD 1269 00:52:02,400 --> 00:52:03,800 IDENTIFY SOME SIGNATURES OF 1270 00:52:03,800 --> 00:52:07,880 CLUSTERS, GROUPS IF YOU WILL, OF 1271 00:52:07,880 --> 00:52:08,960 THESE PROTEINS AND ASSOCIATION 1272 00:52:08,960 --> 00:52:10,800 WITH DEATH AND FOUND TWO 1273 00:52:10,800 --> 00:52:13,680 CLUSTERS THAT CARRIED A VERY 1274 00:52:13,680 --> 00:52:15,760 DIFFERENT MEANING WHEN IT CAME 1275 00:52:15,760 --> 00:52:17,600 TO THE SURVIVAL OR PROBABILITY 1276 00:52:17,600 --> 00:52:18,480 OF SURVIVING LONGER TIME PERIOD, 1277 00:52:18,480 --> 00:52:21,360 IF YOU WERE IN THE RED CLUSTER 1278 00:52:21,360 --> 00:52:23,200 ABOVE ON THE TOP CURVE YOU WERE 1279 00:52:23,200 --> 00:52:26,280 GOING TO SURVIVE MUCH, MUCH 1280 00:52:26,280 --> 00:52:27,680 LONGER, STILL BAD OUTCOME, MUCH 1281 00:52:27,680 --> 00:52:29,800 LONGER THAN THE PEOPLE IN THE 1282 00:52:29,800 --> 00:52:31,720 BLUE CLUSTERS WHO DIED MUCH 1283 00:52:31,720 --> 00:52:31,960 SOONER. 1284 00:52:31,960 --> 00:52:37,440 TO QUANTIFY THE RISK OF DEATH 1285 00:52:37,440 --> 00:52:43,680 ASSOCIATE WITH BLUE WE USEDs 1286 00:52:43,680 --> 00:52:45,320 HAS HAZARD RATIO. 1287 00:52:45,320 --> 00:52:47,840 IF WE TAKE INTO ACCOUNT ALL OF 1288 00:52:47,840 --> 00:52:49,360 THE OTHER CLINICAL FACTORS THAT 1289 00:52:49,360 --> 00:52:50,920 WE ALREADY KNEW, REMEMBER THAT'S 1290 00:52:50,920 --> 00:52:52,640 THE INCREMENTAL QUESTION WE 1291 00:52:52,640 --> 00:52:55,480 WANTED TO ASK, IT'S STILL ALMOST 1292 00:52:55,480 --> 00:52:56,600 TWO-FOLD INCREASE IN RISK OF 1293 00:52:56,600 --> 00:52:57,640 DEATH. 1294 00:52:57,640 --> 00:53:00,880 SO IT'S VERY LARGE INCREASE, 1295 00:53:00,880 --> 00:53:02,080 ASSOCIATED WITH PROTEOMIC 1296 00:53:02,080 --> 00:53:08,080 SIGNATURES, INDEPENDENT OF THE 1297 00:53:08,080 --> 00:53:08,640 EJECTION FRACTION. 1298 00:53:08,640 --> 00:53:13,000 INTERESTED IN KIDNEY DISEASE, 1299 00:53:13,000 --> 00:53:13,800 KIDNEY IS CRITICALLY IMPORTANT, 1300 00:53:13,800 --> 00:53:16,160 COMORBIDITY CARRIES THE RISK OF 1301 00:53:16,160 --> 00:53:16,960 ADVERSE OUTCOME. 1302 00:53:16,960 --> 00:53:24,040 THERE'S A PROTEOMIC SCORE THAT 1303 00:53:24,040 --> 00:53:25,680 THE COMPANY SOMALOGIC 1304 00:53:25,680 --> 00:53:27,240 IDENTIFIED, IDENTIFYING BEFORE 1305 00:53:27,240 --> 00:53:35,440 THE CLINTON CAT CREATININE OR 1306 00:53:35,440 --> 00:53:36,960 ESTIMATE OF GFR SCORE, LINEAR 1307 00:53:36,960 --> 00:53:38,360 RELATIONSHIP WITH INCREASING 1308 00:53:38,360 --> 00:53:41,880 RISK OF DEATH ASSOCIATED WITH 1309 00:53:41,880 --> 00:53:43,320 WORSENING PROTEOMIC SCORE 1310 00:53:43,320 --> 00:53:45,920 REFLECTING KIDNEY FUNCTION. 1311 00:53:45,920 --> 00:53:51,320 WHAT ABOUT THE METABOLOMICS? 1312 00:53:51,320 --> 00:53:54,680 AS WE'VE CONCEPTUALIZED, 1313 00:53:54,680 --> 00:53:55,280 INTUITIVE TO THINK METABOLOMIC 1314 00:53:55,280 --> 00:53:57,320 ENTITIES WILL MAP OUT TO ADVERSE 1315 00:53:57,320 --> 00:54:01,680 OUTCOMES, WE'RE FORTUNATE TO BE 1316 00:54:01,680 --> 00:54:09,080 ABLE TO COLLABORATE AND DO NMR 1317 00:54:09,080 --> 00:54:09,680 SPECTROSCOPY, MEASURING 25 1318 00:54:09,680 --> 00:54:12,200 METABOLITES, I DON'T HAVE TIME 1319 00:54:12,200 --> 00:54:15,080 TO DETAIL THIS BUT GIVE CREDIT 1320 00:54:15,080 --> 00:54:17,720 WHERE CREDIT IS DUE, TO FOUR 1321 00:54:17,720 --> 00:54:21,160 STUDIES LED BY FOUR INDIVIDUALS, 1322 00:54:21,160 --> 00:54:25,400 ON THE TOP LEFT DR. JOO, WE'RE 1323 00:54:25,400 --> 00:54:31,040 SO EXCEPTIONAL FORTUNATE TO WORK 1324 00:54:31,040 --> 00:54:33,880 WITH, IDENTIFIED SPECIFIC 1325 00:54:33,880 --> 00:54:38,280 METABOLOMIC SIGNATURES OF HEART 1326 00:54:38,280 --> 00:54:44,720 FAILURE ON TOP LEFT, REBECCA 1327 00:54:44,720 --> 00:54:45,280 OYETORO, ADVERSE ASSOCIATION 1328 00:54:45,280 --> 00:54:48,760 WITH KETONE BODIES AND SURVIVAL. 1329 00:54:48,760 --> 00:54:51,960 REBECCA DID THAT AND SHOWED 1330 00:54:51,960 --> 00:54:52,720 KETONE BODIES AS OPPOSED TO 1331 00:54:52,720 --> 00:54:56,440 POPULAR BELIEF IS BAD FOR YOU, 1332 00:54:56,440 --> 00:54:57,880 NOT AN INNOCENT BYSTANDER IN THE 1333 00:54:57,880 --> 00:55:01,800 SETTING OF HEART FAILURE. 1334 00:55:01,800 --> 00:55:05,680 KATIE CONERS, UPPER RIGHT, NICE 1335 00:55:05,680 --> 00:55:08,320 ASSOCIATION, GRADED ASSOCIATION 1336 00:55:08,320 --> 00:55:08,960 WITH MALNUTRITION INFLAMMATION 1337 00:55:08,960 --> 00:55:12,720 SCORE, OUTCOME OF HEART FAILURE. 1338 00:55:12,720 --> 00:55:14,880 AND SARAH TURECAMO, THE PROJECT 1339 00:55:14,880 --> 00:55:17,880 WE'RE WORKING AT FINISHING, 1340 00:55:17,880 --> 00:55:21,840 ASSOCIATION OF ANOTHER COMPOSITE 1341 00:55:21,840 --> 00:55:22,720 SCORE, LIPOPROTEIN RESISTANCE 1342 00:55:22,720 --> 00:55:25,640 INDEX AND SURVIVAL IN HEART 1343 00:55:25,640 --> 00:55:25,880 FAILURE. 1344 00:55:25,880 --> 00:55:26,960 IMPORTANTLY ALL ASSOCIATIONS, 1345 00:55:26,960 --> 00:55:28,920 PRELIMINARY DATA, WERE 1346 00:55:28,920 --> 00:55:30,000 INDEPENDENT OF THE EJECTION 1347 00:55:30,000 --> 00:55:32,120 FRACTION AND OF KEY CLINICAL 1348 00:55:32,120 --> 00:55:32,760 INDICATORS KNOWN TO CLINICIANS 1349 00:55:32,760 --> 00:55:34,760 OR SHOULD BE KNOWN TO CLINICIANS 1350 00:55:34,760 --> 00:55:37,240 WHEN THEY CARE FOR HEART 1351 00:55:37,240 --> 00:55:37,480 FAILURE. 1352 00:55:37,480 --> 00:55:40,200 WHAT CAN WE CONCLUDE AT THE END 1353 00:55:40,200 --> 00:55:47,080 OF THE PILOT STUDIES? 1354 00:55:47,080 --> 00:55:48,080 MOLECULAR PHENOTYPING CAN 1355 00:55:48,080 --> 00:55:50,280 IDENTIFY SIGNATURES AND PROVIDE 1356 00:55:50,280 --> 00:55:52,280 INFORMATION OVER CLINICAL 1357 00:55:52,280 --> 00:55:52,680 FACTORS. 1358 00:55:52,680 --> 00:55:56,920 WE HAVE A LOT LEFT TO DO, 1359 00:55:56,920 --> 00:55:57,720 STUDIED CLINICAL PHENOTYPES, 1360 00:55:57,720 --> 00:55:59,920 WORK ON THE WAY, AND IT'S 1361 00:55:59,920 --> 00:56:02,000 IMPERATIVE THAT WE STUDY 1362 00:56:02,000 --> 00:56:03,840 DIFFERENT POPULATIONS FOR THE 1363 00:56:03,840 --> 00:56:07,200 EXTERNAL VALIDATION, ALSO FIRST 1364 00:56:07,200 --> 00:56:12,640 AND FOREMOST TO STUDY DIVERSE 1365 00:56:12,640 --> 00:56:12,920 POPULATIONS. 1366 00:56:12,920 --> 00:56:18,200 I'LL TRY TO BE BRIEF WILL -- DU 1367 00:56:18,200 --> 00:56:21,800 MUST ACKNOWLEDGE THE TEAM AT THE 1368 00:56:21,800 --> 00:56:23,120 MAYO CLINIC, THEY HAVE BEEN 1369 00:56:23,120 --> 00:56:24,320 INSTRUMENTAL, THE ONES WHO DID 1370 00:56:24,320 --> 00:56:26,760 THE WORK I'VE SHARED WITH YOU 1371 00:56:26,760 --> 00:56:27,400 DONE OVER THERE. 1372 00:56:27,400 --> 00:56:30,120 AND IT WAS JUST AN INCREDIBLE 1373 00:56:30,120 --> 00:56:33,400 RIDE WORKING WITH ALL OF THEM. 1374 00:56:33,400 --> 00:56:34,520 WHAT IS EQUALLY INCREDIBLE IS 1375 00:56:34,520 --> 00:56:35,960 SINCE JOINING NHLBI I'VE BEEN SO 1376 00:56:35,960 --> 00:56:37,360 FORTUNATE TO BE ABLE TO BE 1377 00:56:37,360 --> 00:56:39,120 WORKING WITH THE TEAM THAT'S AT 1378 00:56:39,120 --> 00:56:40,560 THE BOTTOM RIGHT OF THE SLIDE, 1379 00:56:40,560 --> 00:56:41,400 SHOWN HERE. 1380 00:56:41,400 --> 00:56:43,720 YOU'VE SEEN THEIR WORK. 1381 00:56:43,720 --> 00:56:45,880 THEY HAVE ROLLED UP THEIR 1382 00:56:45,880 --> 00:56:47,760 SLEEVES PROMPTLY AS WE STARTED 1383 00:56:47,760 --> 00:56:49,680 WORKING TOGETHER, AND THEY ARE 1384 00:56:49,680 --> 00:56:54,560 JUST AMAZING TO WORK WITH. 1385 00:56:54,560 --> 00:56:56,400 EQUALLY AMAZING ARE 1386 00:56:56,400 --> 00:56:58,160 COLLABORATORS DR. JOO, THE MOST 1387 00:56:58,160 --> 00:57:06,720 AMAZING PARTNER THAT WE DO DREAM 1388 00:57:06,720 --> 00:57:07,720 OF, TIFFANY POWELL WILEY IS 1389 00:57:07,720 --> 00:57:15,640 THERE TO GUIDE US IN OUR WORKING 1390 00:57:15,640 --> 00:57:19,400 IN THAT DIRECTION. 1391 00:57:19,400 --> 00:57:24,960 ALAN REMALEY FOR METABOLOMICS 1392 00:57:24,960 --> 00:57:28,600 WORKS, AND FINALLY VANDERBILT 1393 00:57:28,600 --> 00:57:29,560 COLLABORATORS FOR THE COHORT 1394 00:57:29,560 --> 00:57:31,080 STUDY NOTHING SHORT OF 1395 00:57:31,080 --> 00:57:31,400 EXCEPTIONAL. 1396 00:57:31,400 --> 00:57:33,320 FINALLY I THANK ALL THE THE 1397 00:57:33,320 --> 00:57:36,560 PATIENTS WHO HAVE GIVEN SAMPLES, 1398 00:57:36,560 --> 00:57:37,760 INFORMATION, HAVE BEEN SUCH 1399 00:57:37,760 --> 00:57:40,520 MAJOR CONTRIBUTORS TO THIS WORK, 1400 00:57:40,520 --> 00:57:41,480 AND FINALLY, VERY FINALLY, THANK 1401 00:57:41,480 --> 00:57:43,400 ALL OF YOU FOR YOUR PATIENCE. 1402 00:57:43,400 --> 00:57:45,000 WE'VE COVERED A LOT OF TERRAIN, 1403 00:57:45,000 --> 00:57:47,400 AND I'M HAPPY TO ANSWER ANY 1404 00:57:47,400 --> 00:57:48,600 QUESTIONS IF TIME PERMITS. 1405 00:57:48,600 --> 00:57:51,000 THANK YOU. 1406 00:57:51,000 --> 00:57:52,600 1407 00:57:52,600 --> 00:57:54,960 >> DR. ROGER, THANK YOU VERY 1408 00:57:54,960 --> 00:57:56,600 MUCH FOR THIS EXCEPTIONAL 1409 00:57:56,600 --> 00:57:56,920 PRESENTATION. 1410 00:57:56,920 --> 00:58:00,880 OPENING OUR EYES TO EPIDEMIC OF 1411 00:58:00,880 --> 00:58:02,880 HEART FAILURE, AND ESPECIALLY TO 1412 00:58:02,880 --> 00:58:06,240 DISPARITIES THAT EXIST IN THE 1413 00:58:06,240 --> 00:58:07,520 GROUPS LIKE UNDERREPRESENTED 1414 00:58:07,520 --> 00:58:07,800 MINORITIES. 1415 00:58:07,800 --> 00:58:13,920 THERE'S A LOT OF CONFOUNDERS AND 1416 00:58:13,920 --> 00:58:14,760 COMORBIDITIES, BUT YOUR 1417 00:58:14,760 --> 00:58:16,760 SOPHISTICATED RESEARCH AND 1418 00:58:16,760 --> 00:58:23,200 PRESENTATION OPENED OUR EYES WHO 1419 00:58:23,200 --> 00:58:25,040 SORTING OUT RISK FACTORS AND 1420 00:58:25,040 --> 00:58:26,880 NEED TO ENGAGE WITH DIVERSE 1421 00:58:26,880 --> 00:58:27,240 GROUPS. 1422 00:58:27,240 --> 00:58:30,440 WE HAVE TIME FOR AT LEAST ONE 1423 00:58:30,440 --> 00:58:31,560 QUESTION. 1424 00:58:31,560 --> 00:58:32,520 SO I'LL START WITH THIS. 1425 00:58:32,520 --> 00:58:35,040 HOW DO YOU ACCOUNT FOR THE 1426 00:58:35,040 --> 00:58:36,240 SEVERITY OF EACH COMORBID 1427 00:58:36,240 --> 00:58:38,960 CONDITION SUCH AS DIABETES AND 1428 00:58:38,960 --> 00:58:40,600 THE EPIDEMIOLOGY STUDY? 1429 00:58:40,600 --> 00:58:43,040 OFTEN THE DISEASE LABELS INCLUDE 1430 00:58:43,040 --> 00:58:46,640 PATIENTS ACROSS A WIDE SPECTRUM 1431 00:58:46,640 --> 00:58:52,600 OF DISEASE SEVERITY SUCH AS 1432 00:58:52,600 --> 00:58:57,400 HEMOGLOBIN A1c OF 7 WITH 1433 00:58:57,400 --> 00:58:57,880 PROGNOSTIC IMPLICATIONS. 1434 00:58:57,880 --> 00:59:01,320 >> WE STRIVE TO ACCOUNT FOR 1435 00:59:01,320 --> 00:59:06,480 DIABETES OR SEVERITY OF CHRONIC 1436 00:59:06,480 --> 00:59:08,800 OBSTRUCTIVE PULMONARY DISEASE. 1437 00:59:08,800 --> 00:59:09,880 SOMETIMES IT'S NOT AVAILABLE, 1438 00:59:09,880 --> 00:59:11,280 AND IF IT'S NOT AVAILABLE THEN 1439 00:59:11,280 --> 00:59:14,760 WE HAVE TO ACKNOWLEDGE IT'S A 1440 00:59:14,760 --> 00:59:16,880 LIMITATION, SHOULD NOT STOP US 1441 00:59:16,880 --> 00:59:18,360 STUDYING DIABETES BECAUSE IF WE 1442 00:59:18,360 --> 00:59:22,680 CAPTURE SIGNAL IT'S GOING TO 1443 00:59:22,680 --> 00:59:24,400 HELP OTHERS DO MORE PRECISE 1444 00:59:24,400 --> 00:59:24,840 STUDIES. 1445 00:59:24,840 --> 00:59:29,120 WE DID A STUDY OF COPD AND RISK 1446 00:59:29,120 --> 00:59:38,520 OF HEART FAILURE, MAYO CLINIC 1447 00:59:38,520 --> 00:59:39,120 POPULATION, 40% DIDN'T HAVE 1448 00:59:39,120 --> 00:59:41,920 PULMONARY FUNCTION TEST. 1449 00:59:41,920 --> 00:59:44,960 WE'RE INTERESTED IN QUANTIFYING 1450 00:59:44,960 --> 00:59:47,840 SEVERITY BUT WE DIDN'T HAVE THE 1451 00:59:47,840 --> 00:59:49,600 TEST, HOPING PEOPLE WERE 1452 00:59:49,600 --> 00:59:51,680 INTERESTED IN INTERSECTION OF 1453 00:59:51,680 --> 00:59:52,440 HEART FAILURE AND RESPIRATORY 1454 00:59:52,440 --> 00:59:54,520 DISEASE WILL DO THE NEXT STUDY 1455 00:59:54,520 --> 00:59:59,040 WHICH WILL BE A BETTER STUDY. 1456 00:59:59,040 --> 01:00:01,640 >> THAT TAKES US UP TO THE HOUR. 1457 01:00:01,640 --> 01:00:04,760 THANKS FOR SHARE YOUR EXPERTISE. 1458 01:00:04,760 --> 01:00:06,320 THANK YOU FOR JOINING US. 1459 01:00:06,320 --> 01:00:07,640 WE'LL SEE EVERYONE NEXT WEEK. 1460 01:00:07,640 --> 01:00:08,040 THANK YOU VERY MUCH. 1461 01:00:08,040 --> 00:00:00,000 >> THANK YOU SO MUCH.