 as well for organizing this. I'm just going to, I don't think I have a disclosure slide, but I really won't be talking about any medications or any assessment systems in particular, so I've got no conflicts of interest to disclose. I'm gonna talk a little bit about some medicine, but really the issue here is more to think about healthcare systems. And there's many different diseases out there, and there's lots of advocacy for different diseases, and I'm not going to advocate that one disease is more important than another. If you have a condition and it's making you miserable, then that's important. But what I wanna do is use heart failure as an example of a condition that seems to pick off many different aspects of what's going on with the healthcare system. And there's a lot of evidence about how to manage heart failure, but it's almost like a perfect storm of issues that have arisen over the last several decades, which have come to a head, but that offer an opportunity. And if we solve this for heart failure, we will have solved it for other chronic illnesses of aging, but also any other chronic illness, be it pediatric, mental health, whatever. And so again, there'll be a little bit of medicine. I've got some nice, gory pictures for those who might be interested, and I'm also warning those who might be having lunch. They're not too bad, but you might wanna be prepared. So let me talk a little bit about heart failure. So heart failure does not mean sudden death. Heart failure is more of a syndrome, and it's a complex syndrome. It's a chronic syndrome. We're gonna talk about chronic disease and what that means. And it results when abnormal heart function results in or increases the subsequent risk of signs and symptoms of poor cardiac output and congestion. And the little cartoons on the bottom highlight some of the main features of these issues. So poor cardiac output, people are tired, fatigable, they might even feel cold because the cardiac output is poor, they're not pumping blood adequately. The x-ray that you've got there, again, we're not gonna turn everyone into radiologists, but you can see the heart is very large. And the lung fields on either side are kinda cloudy. And that cloudy stuff for those who have never seen x-rays, that's water. So heart failure causes the accumulation of fluid in your chest, and you can imagine that you're basically drowning, and it's a rather unpleasant thing to have. And the two pictures on the right, you can see this lady's cut two signs. One is the oxygen tube, the little plastic tube there. And her jugular vein is very distended, which reflects, again, the accumulation of extra fluid in her system, which you can see in the ankle swelling. When you push down on that swelling, it leaves an indentation. So those are some of the cardinal features of heart failure, but obviously you can imagine it's hard to move that extra fluid around. Your heart's not pumping while it's even more difficult, and you can't breathe. So it's a very miserable chronic condition. Now, before we go on, it's important to understand the difference between acute disease and chronic disease, because that has implications on the healthcare system, which you'll see is designed primarily to deal with acute disease. So an acute condition usually comes on suddenly, usually has a brief course, often resolves completely, but may leave permanent problems. The goal of an acute illness is to cure, and its duration is fairly brief, and the cost is usually minimal. And I think a classic acute condition is pneumonia. Pneumonia, the symptoms come on very quickly. With appropriate antibiotics, the course is fairly brief. It may take a couple of months to recover, but generally most people get the right antibiotics and they're cured. And the course of the antibiotics is generally fairly affordable, and if someone is hospitalized, it generally is for a brief amount of time, so the cost of an acute pneumonia is very minimal. Versus chronic diseases like heart failure, which come on over time, they usually arise in early life and don't cause symptoms until some sort of event develops. So there's a symptom-free period, and all of a sudden it comes to the fore when somebody all of a sudden is sick. And so you can imagine heart failure. You've got this heart problem that over time starts to cause subclinical or symptom-free problems, and all of a sudden fluid accumulates in the lungs and you're suddenly presenting with heart failure. But the problem has been there for a while. Heart failure as other chronic illnesses are lifelong and they generally progress. There is usually no cure, and the course is one of remissions and relapses. So you get better and then the disease decompensates and you treat that, and you get better for a while and the disease again decompensates. The goals go from prolonging life, perhaps earlier in the course, to more maintaining quality of life and function. It might include some rehabilitation, but invariably end-of-life care becomes the primary goal. And the duration of the illness is generally lifelong, and of course the cost is very high because this is not a curable disease and it's something that you have to deal with for a very long time. So that's the difference between acute and chronic disease and remember that because that'll be important when we get into some of the nitty-gritty of the talk. Just a little bit of physiology here and there, but we think of the heart as basically a pump. So as a pump, it has to push blood out and into the body, into the head, the intestines, the organs, and it has to fill. And you can see there are two arrows there. The right ventricle is the part of the heart that pumps blood into the lungs. It's not a very thick part of the heart because it doesn't have to push the blood very far. The left ventricle is the main pump. And as you can see, the walls of the pump are fairly thick. So we talk about heart failure in two main scenarios. There's a variety of other ones, but the main ones are heart failure with preserved ejection fraction, which basically means that the pump is emptying every time the heart beats. Usually the ventricle empties about 50 to 60% of its contents when it beats. So you can have heart failure when the pump is working well, but the ventricle is too stiff. So it doesn't fill properly. And therefore, because it doesn't fill properly, pressure and fluids back up into the lungs, into the legs, and causes that congestion. In heart failure with reduced ejection fraction, the pump has been damaged by some sort of illness and therefore it's a pumping problem. So preserved ejection fraction is primarily a filling problem. Reduced ejection fraction is generally a pump problem. So why would heart function be abnormal? The main causes are coronary artery disease. The picture on top here is essentially a pathological slide of a heart. Here's the wall of the right ventricle. Here's the wall of the left ventricle. Couple of things to point out, it is extremely thick. This is probably someone who's been dealing with high blood pressure for a very long time. And imagine doing push-ups for a very long time. Your biceps get very thick. Similarly, if the heart has to pump for a very long time, it will get thick and as it gets thick, it gets stiff and can't fill properly. And right here, what you see here is dead heart tissue. So this person had a fairly large heart attack and probably this is why the person passed away. So coronary disease, hypertension, diabetes, the odd viral illness can cause heart failure. Alcohol is underappreciated but can lead to cardiac dysfunction. Some chemotherapies for cancer and valvular heart disease. And as patients get older, we will see more and more of this thing which is aortic stenosis. So here is the aorta, the main vessel that leaves the heart. And this is the aortic valve and normally this valve opens fairly widely. But as you can see, the valve cuffs themselves have become very thick and nodular. There's lots of calcium and this little hole there, smaller than your pinky, is the hole through which the blood has to come out from the ventricle, from the heart. And that's another cause of heart failure as you can imagine as this gets smaller and smaller, eventually the heart cannot pump enough blood. There are aging changes and we will talk about these later. So why are we talking about heart failure? Well, the first thing is it's extremely common. It's mainly condition that affects older people. So the prevalence in people 65 years or less is about 1% or less. And in people who reach the age of 80 or who are in nursing home, it exceeds 20%. And in some nursing home studies, the prevalence is about 40%. So it's extremely common as you get older. Without going into too much detail, it is a high cause of mortality. It is a high cause of poor quality of life and morbidity, hospitalizations, re-hospitalizations. It's cost a lot of the healthcare system and it deals with a lot of health system use. It's a very lethal condition. So in Ontario, mortality after first hospitalization is 33% at one year. If a person is older, has comorbidities or dementia, the mortality after one year is 60%. In long-term care, about half of people admitted to a nursing home will have a history of heart failure or deceased within a year. And if they happen to have a heart failure hospitalization during that year, 90% of them will pass away within the rest of the year. So it's a very lethal end-stage condition. But until you pass away, it is one of the most common causes of hospitalization in people over the age of 65. And readmission rates can be extremely high between 23 and 50% of three months. The inpatient costs have been associated, have been calculated in Canada will be around $3 billion in the next 12, 13 years. And the burden is increasing. So we have projections adapted from StatsCan from 2006 to 2056. And you can basically see that the burden of heart failure will approximately triple over the next 30 to 40 years. And again, that's because people who get heart failure also happen to be people who are older. And as we all know, our population's aging. The burden on the healthcare system will also triple. And we can see the projected heart failure admissions in Canada, these are 10-year-old projections. Nothing has occurred to make those projections be any different. High burden, therefore, on the healthcare system. If we look at the discharge abstract database maintained in Canada, you can see the total number of heart failure hospitalizations compared to hospitalizations for other causes. The main thing you wanna look at here and start thinking about is the number of comorbidities. So heart failure patients have a lot more other problems than patients who don't have heart failure. In-hospital mortality is also very high and the length of stay is also very high. So again, a very complex disease that is associated with a lot of patient complexity, which drives a lot of health system utilization. Heart failure treatments are better than they used to be, but it's still a fairly lethal disease. So in the 1970s, before we had evidence-based medications, mortality was about 50% at a year for all comers. And it has declined gradually and there have been a lot of advances in pharmacotherapy for especially heart failure with reduced ejection fraction, but really the improvements in survival have stalled recently. So the median survival remains at two years and by 10 years, most people with heart failure are no longer with us. And as you can see from US Medicare trends in 1999, overall mortality was about 32% and 10 years later it remains at 32%. There's a bit of a need here in 2004, but it started to come back up and this probably reflects the aging of the heart failure population. So it's a big problem and the question is how do we get here? So I would suggest that there are three main things. We got to this point because in the 1950s, we created a healthcare system that was designed mainly for acute disease and this is a chronic illness and we'll see how that causes trouble. We then, and I use that in quotes, we created a chronic disease and I'll explain why that is that is more common in older persons and populations aging. So let's go through these one by one. So getting healthcare system goes back to the 1950s where it began with something called Hospital Insurance and Diagnostic Services Act for the federal government which started sharing costs with the provinces for services primarily in acute hospitals. Move forward to 1984, again, Canada Health Act and trying that provinces were responsible to administer and deliver healthcare. They would take the money and they would figure out what priorities they wanted to spend it on. At the core, however, of our healthcare system are the insured services that are all covered uniformly which are essentially still medically necessary hospital, inpatient and ambulatory services. And by medically necessary, we mainly talk about services provided by physicians either in an office, a hospital or another setting. There are other services and that are covered in part by many provinces but differently but they're not actually really covered by the Canada Health Act. So drug plans, home care, long-term care and rehab. And these things were added by the provinces after the fact in a bit of a piecemeal way and they are certainly not integrated with one another. They don't share EMRs, they don't have standardized assessments, communications are rather poor. So as a result, we have a system that remains centered on hospital care. There have been changes in the last couple of years but we still have a lot of emphasis on hospital care. And it's a system that is geared towards the care of acute illnesses which was fine in the 1950s because we really didn't have a lot of evidence-based medicine to deal with things like coronary disease. People had heart attacks and really did not live much longer. As a result, care processes and the fee schedule for physicians is tailored to addressing acute problems. So that's why we have brief visits because you get paid per visit. Clinician training still is mainly hospital-based for many people as opposed to the community. And so of course the perspective that for example, I received when I was training in geriatric medicine with respect to heart failure was what it looked like when they came to the emergency. And as you'll see, the action really has to be in the community. So we'll park those thoughts now with respect to the system and talk a little bit more about how we created this chronic disease. So the 1970s, 80s, 90s and so on saw an explosion in therapeutics for cardiology in particular. So evidence-based cardiology was quite big and remains quite big. And the big changes were better hypertension control and better medications, better therapies for acute heart attacks and coronary artery disease with stents and thrombolytics and surgery. Brand pharmaceutical, which had a huge impact on survival of patients with coronary disease. So cholesterol lowering pills, the statin, aspirin and anti-platelet drugs, ACE inhibitors for example. Prevention, lots of emphasis in public health on reducing smoking rates and the science of rehabilitation. And so people would develop a cardiovascular disease and we have very good therapies for that now. And so they do a lot better over time. And we can see that this is data from the Public Health Agency of Canada that from 1969 to 2004 from this report, we can see the falling death rates due to myocardial infarction which have been both benefited by women and by men. And we can see how substantially the rates of death have fallen over those 30 or so years from nearly, if we look at men from almost 300 per 100,000 population down to about 75, so a four-fold reduction, not as dramatic unfortunately in women. But nonetheless, we are good at keeping people alive with coronary disease. And that's the point, they're staying alive. We haven't cured them, we treat blood pressure, we treat atherosclerosis, but we thus far are unable to cure it. And so people live longer with cardiovascular disease and we can see here again from the same Public Health Agency in Canada report, rates of hospitalization due to ischemic heart disease in 2005, 2006, and we can see what's going on. It's really seniors who are coming to the hospital with these conditions, the prior to success. And as a result, they have underlying heart disease and the natural history is over time, even though they're on evidence-based therapies, they go on to develop heart failure. And you can see here hospitalization rates based by age and you can essentially see that the bulk of people who are affected by heart failure are 75 and over. So we've talked about the system and let's talk about evidence-based cardiology. It has made a big difference in the lives of people. So we have significantly greater survival of people with cardiovascular risk factors and cardiovascular disease but they have not been cured. And so they grow old with these conditions and these conditions therefore become chronic. And as a result of having chronic risk factors, they develop heart failure. But there's more to it than that. What happens because of age? Thomas Sydenham was said to be the father of medicine in England and this is a quote that's been attributed to him that a man is as old as his arteries. I've modified that a little bit. Women are as old as their arteries as well. But it's been recognized for many years, many centuries. And in fact, the Egyptians 3,500 years ago had noticed that people with heart disease developed features that were akin to old age. Before we get into that, here's your physics lesson. As Mark pointed out, I do have a degree in engineering so I hope I can make this easily understood. We have to understand the physics of waves. So over here on the left, you have two strings. The red string is fairly thin and it's connected to a blue string, which is fairly thick. And if I'm standing there with the red string in my hand, I can make a little blip. I can send a little wave down there and the waves gonna travel. When it hits that boundary, two things happen. When there's a boundary where the two media are not well matched, there will be a reflection. And if there's a significant difference in the boundaries density, the reflection will be fairly large. There will be some transmission of the energy distally down the more dense medium. There will also be a reflection. If the densities of these two strings became more and more closely matched, there is going to be more transmission of the wave into the blue side and less of the reflection. So the important thing is here, the boundary. It's the boundaries between two media that have a very significantly different density. There will be some attenuation of the pressure wave or the pulse wave as it goes down here and some reflection back. And you can see that if you play with prisms. So essentially there's a light source here. The light hits the piece of glass at an angle. The density of glass is different from that of air. So there's some reflection here and there's transmission of some light through the prism. There's a bit of a bend here because the waves slow down. And when they slow down, there's gonna be a bit of a bend that's called refraction. And when it hits the other boundary, again, there's a bit of a reflection here and the rest is transmitted further. So that's how waves work. And you're probably wondering, what the heck is he talking about? So this is what we're talking about. On the left is a diagram of our arteries. There's a lot of arteries and you don't have to memorize the names of all the arteries. I certainly have not. But there are three main kinds. There's the big ones here that leave the heart, the aorta that goes down into the abdomen and feeds the legs with the femoral arteries. And then there's the arteries that feed the arms and the ones that go up into the head. These are very large and they're also quite elastic. Remember that, because that's important. They stretch. As they get further along the course and start branching off and starting to supply muscles, they become more muscular. And that's because you wanna control the amount of blood that gets there to the muscles. And so they're muscular, therefore they're stiffer. There you go. You've got a difference here in the density of the main big arteries and the muscular arteries. And when you finally get into the capillaries, which is where oxygen and carbon dioxide exchange happens, you have this very wide web where pressure falls substantially. And really that's what you want. You don't want this gigantic wave pulse to hit these little capillaries going full speed and blowing them apart. You basically want to start attenuating the pressure wave by introducing different densities and reducing the pressure of the blood being distributed further on. So basically your arteries are conduits for blood pressure waves. And each time the heart beat, it sends a wave of pressure and drives the blood beyond the heart and down into the blood vessels. So the major arteries have a lot of something called elastin, which allows them to stretch. And the muscular arteries a little bit stiffer and their purpose is to cushion or dampen the capillary beds and the organs distally to protect them into an alpha-proper gas exchange. So different impedance. That's the wave reflection bit that we started off with with the wave physics. So when the heart beats insistently, it ejects blood from the left ventricle and this great big bolus of blood goes into the aorta. And the aorta is very elastic and so it expands like a balloon. The blood comes out of the ventricle which is like this child's head into the aorta which is like this balloon and the aorta stretches to accommodate all of that energy. And because of that, that's how we don't have the pressures in the aorta aren't too high. Basically because the vessel stretches, it kind of takes some of that energy and reduces the pressure. So again, remember you've got this pressure wave that leaves the heart going down these elastic arteries and then it finally hits these muscular arteries which have a different density. And so there will be some transmission of the pressure wave beyond that boundary into the arteries and arterial. There will also be some pressure that gets reflected back towards the heart. And you can see that here. There's the pressure wave going, hits the boundary. Some of it goes forward and some of it bounces back. Now this partially reflected pressure wave, again it's not the bulk of the pressure, most of the pressure drives the blood forward which is what we want. We want to feed the organs and the muscles. But that little bit of pressure which goes back to the wards, the heart is impeccably timed because of the way that the aorta is stretchy. It gets back just after the heart has finished emptying and the valves close. So it just arrives right after the heart is finished emptying again, the valves are closed. And what this does is of course when the heart is finished pumping what's going to support the blood pressure? The heart has stopped pumping. The reason we don't have a zero blood pressure after the heart starts pumping is because this pressure wave comes back and maintains that blood pressure. And that's why we have a blood pressure of 120 over 70 when you've gone to the doctor and you get these values, you're happy. The other thing is this pressure wave comes back here and right here the coronary arteries that give blood to the heart muscle itself are opened up by that pressure and the heart gets its own blood supply. So this is exquisitely tuned. The density here and the density there are exquisitely tuned to support blood pressure when the heart is no longer pumping and to provide blood supply to the heart muscle itself. It's really quite spectacular. With age, and as you'll see it's not just because we get older it's because we sit around and don't exercise. With age we're out of shape. The heart beats faster. And if you were to take an elastic band and stretch it and relax it very quickly over time eventually it'll rupture. And essentially that's what happens to the elastin in those big blood vessels. Over time, especially if we're not in shape and our heart rates are fast these elastic bands inside the blood vessel walls break. And when something breaks in the body it gets replaced with scar tissue, collagen. And what happens is as you lay down that scar tissue the walls get thicker. The other thing that happens is there's proliferation of muscle cells where they shouldn't be in those arteries. And so the artery actually gets thicker and stiffer. The muscular arteries also tend to be more stiff but the big changes are in those great big elastic vessels they lose their elasticity. So go back to your physics. Because the blood vessel is now stiff it's like having a balloon that's really really stiff. And you know when you've got these balloons that won't inflate and you're blowing and blowing and blowing and you feel like your head's gonna pop well that's what happens. The pressure remains very high because the blood vessel will not distend when the heart pumps out of it. And that leads to systolic high blood pressure because the heart has to push harder into a vessel that will not accommodate the blood. So that's one problem that happens. The second problem that happens is if you remember that boundary. Normally you've got a very distensible aorta and some stiffer of arteries over here but if the aorta becomes as stiff as the muscular arteries two things happen. You've lost that boundary and so therefore the pulse pressure keeps going. And there's very little reflection back. The other thing that happens is because the blood vessel is stiff speed by which the pressure travels is also faster. You can imagine the corollary to that is if you've got a garden hose and the flow is poor you put your finger at the front of the garden hose you're trying to make the thing a bit stiffer and you can see the flow of the water start to increase. It's faster. And this is what happens if you have a tighter blood vessel blood pressure will the blood pulse will go down distally more rapidly. There'll be a bit of a reflection and it'll come back more rapidly. So that's not good because over here you've got your brain and you've got your kidneys in particular and all of a sudden they're being exposed to really high pressures and that will damage them. Meanwhile that little feeble pressure being sent back arrives early. So it arrives when the heart is still trying to empty. So if you imagine you're trying to it's like that balloon you're blowing into that balloon and then somebody comes by and squeezes the balloon and the air pops back into your mouth. You have to work harder. So the heart has to work harder. That's not good for the heart. And on top of that having to work harder you can imagine that this little pressure arrives too soon and it's not enough to supply blood to the coronary arteries. And so therefore your heart which is working harder is now also getting less blood supply for itself. Two bad things. And finally the other thing is that your diastolic blood pressure which normally depends on the reflected wave to be maintained no longer has much of a reflected wave. And so your diastolic blood pressure falls. So you get high blood pressure in the systole and low blood pressure in diastole. So we'll see what that leads to. So basically your blood vessels are stiffer. You get high systolic blood pressure and low diastolic blood pressure. The workload on the heart increases. You get cardiac muscle enlargement called hypertrophy and it becomes stiff. And you remember heart failure includes a filling problem and stiff hearts can't fill properly. And the blood supply to the heart muscle itself is compromised. And so the heart starts to lack oxygen and that can lead to scarring which leads to problems with stiffness. The high blood pressure leads to strokes can lead to dementia, can lead to kidney failure. And what you see here are little areas in the white matter of someone's brain. These large gaps are not normal. Some of them are strokes and some of them are damage related to blood vessels trying to fight off this high pressure coming from the heart. And of course, if you have low diastolic blood pressure people faint or they fall and that way they can have another impact on their overall health. And so you've got a lot of things going on. We've got comorbid conditions. We have vascular risk factors with which people live longer. There's obviously environmental issues like pollution and others and genetics that we can't get away from. And we have hardening of the artery and people are living longer with this. And on top of that underlying all of this stuff is vascular aging. And so you have multiple factors contributing to damaging your vascular system, damaging your heart and therefore predisposing to heart failure. One of the key things however is people who are physically active have slower vascular aging. Sometimes we've got vascular aging that leads to additional cardiac injury and thus increases the risk for heart failure over time. Generally contributes to cardiovascular risk. We know that high blood pressure itself accelerates hardening of the artery and it leads to additional medical problems like stroke, like dementia, like kidney failure. And if you thought that was it then there's more. So in the last 15 years we have now become quite aware that heart failure is not just a medical thing. Michael Rich in St. Louis calls it a cardiogeriatric syndrome. He calls it that because what we've seen is now quite convincingly people who have had heart failure for a long time are more likely to be frail. People with heart failure have a 60% increased risk in cognitive impairment compared to people of their own age and gender matched. People with heart failure who are frail develop non-specific symptoms. So when they're getting sick they may not complain of shortness of breath. They may complain of confusion. They may become delirious. They may have trouble sleeping. People with heart failure lose their function. They become functionally disabled over time especially with each heart failure hospitalization. They become incontinent. If you can imagine you are becoming more frail, have trouble getting around and the doctor gives you medications to make you urinate so you can get rid of all that fluid. Very unpleasant thing. And by definition anyone with heart failure is probably gonna be on five or six pills. And again we know that that increases the risk of adverse drug events. So all of these things that we usually attribute to geriatric issues are part and parcel of the heart failure syndrome in 2017. And the more of these you have, the more rapidly the person declines, the more frequent they have heart failure exacerbations, the more often they're hospitalized and the sooner they die. Just have to look at home care data for Ontario. Basically we compared home care clients with heart failure to those without heart failure. Bit older, some minor differences, but essentially we're more likely to be female, less likely to be living alone. Over half have some degree of cognitive impairment. And that's a problem if the doctor is prescribing five or six pills and you can't remember them. A lot of them have depressive symptoms. A lot of them have basic problems with activities of daily living. Even behaviors that we normally attribute to dementia have a prevalence that's almost the same as home care clients without heart failure. They have more comorbidities. They are on a lot more pills and they require generally more services except physio. No one gives them physio, which is not good. And when you see what happens to them after they go home from hospital and you look at the age, this is data from Ontario from the discharge abstract database. Over the age of 65, the proportion of people who are discharged home with support services like home care, community support services reaches almost one in four. And if you look at the proportion of people who are discharged to a continuing care facility or a nursing home, it's also very high and it disproportionately affects seniors. And so the big picture, if we're gonna put all of this together, is you've got a condition that begins all of a sudden with an exacerbation and they go to hospital, they get better, but they don't quite reach the level they used to be at. They may be well for a few years and then they'll have another exacerbation and lose a bit of ground. And the sicker they get, the more often they get exacerbations and overall their function declines. They may go from being independent in the community to needing home care services or rehab. Sometimes we come up with a therapy that really optimizes their condition and kind of pulls back the clock a little bit, but they still have heart failure. And so they're gonna still be on that course where they become worse over time. They could die at any time and we won't get into the issue of advanced care planning but you could die early or you could die late. You can die from sudden death or you can die from drowning or drop or drown. And that has implications on how you approach people for advanced care planning. Eventually though, they will pass away and most of them will die unfortunately, many of them will die in hospital even though they're very frail and should probably be dying in their nursing home or palliative care. Over time, they become more medically complex. They do developmental health issues like we saw depression and cognitive impairment. They become more frail. They become a greater burden on themselves in terms of their symptom, their caregiver and the healthcare system. And the goals do have to shift as we go over time from perhaps disease modification and longevity at first to more of a quality of life symptom palliation focus later on. Throughout all of that, trying to optimize heart failure therapies is an ongoing challenge because it spans multiple specters of the healthcare system. And so we have this disease in 2017 where we have a lot of people who have heart failure and we will be getting more because we have good treatments for cardiovascular disease but these are not cures. As we get older, our blood vessels age and that has obvious consequences that feed into the risk for heart failure. And we've got more people who are getting older and those are the people who get heart failure. But it's not just that. We have increasing complexity with more and more people with heart failure having geriatric syndromes, having multiple comorbidities and medications. And we have this risk of recurrent episodes and decline that leads to significant health system utilization. And that's where we get back to our discussion about the healthcare system which was initially designed to deal with acute problems. You had your heart attack, you came in, you survived or you didn't. You were working on the farm, you broke your leg, you went in, they fixed it, you went home. Our system is essentially still designed that way. And unfortunately, it's still rather fragmented. So all the sectors are important in the care of the person with heart failure but they don't communicate well. We don't have the standard EMR. We don't have very well executed transitions overall when people are discharged and go back to primary care. There are some good programs out there but sometimes they're not implemented or used properly. And the default often remains, when you get sick, go to the emergency. So the implications, and I'll refer you to O'Connor, he put in a recent timely editorial on this in the Journal of the American Cardiology, Heart Failure. But basically, healthcare systems, what has been shown is healthcare systems that have better heart failure outcomes have better health outcomes overall for other chronic illnesses. And so if we can fix heart failure, we can certainly improve the healthcare system in general. And we have a lot of evidence. So we have a lot of evidence on how to manage heart failure in hospitals and in patient care. We have a lot of evidence on chronic disease programs. We have a lot of evidence for transition of care. We have a lot of evidence with palliative care. We are looking at new models that are showing promise in primary care and in long-term care which are shared care models where the specialists come out of their hospitals and are embedded in primary care and do capacity building as well as care. Interprofessional care, distributing that into primary care in a more effective way is essential to managing heart failure better. We have to look at adapting fee schedules. It is absurd that you get the same fee for looking after a sore throat in primary care as you would for looking at someone with heart failure. The heart failure patient needs a whole hour sometimes and the sore throat might take five minutes but the fees are the same. And we have to start training people in the community to manage these diseases in the community and get them comfortable doing it in that way. And the different partners have to work more effectively together. Prevention is critical. So we talked about the healthcare system but as you saw, we know that a lot of lifestyle issues lead to diabetes and high blood pressure and now we also know that physical activity can prevent vascular aging. This is also a public health issue. And from the LSA's perspective, there's an opportunity to look at vascular aging and consider adding measures of vascular stiffness. And I show my colleague there, Richard Houston, who's at the Faculty of Health Sciences and the RIA as well. He has seen that in space, your arteries, the arteries of the astronauts age about 10 to 30 years. And so this astronaut model is a good model but not a perfect one for what happens to us on earth when we're sedentary. So it's important to start looking at measures of vascular stiffness in longitudinal studies. So just to finish off, heart failure is truly an archetype condition. It's common, it's got geriatric syndromes, it has multimorbidity and it's high system impact. It has a lot of evidence behind it in terms of how to manage the different episodes of heart failure care. We know what to do, we just need to do it and start putting it together as a system. And that's why I would argue if you fix heart failure, you can fix the healthcare system. We had some helpful resources but I'm not sure where the slide went, but anyway, I'm done. So thanks, thank you for the opportunity. Great, thank you very much, George. Very, very interesting presentation. And now I'd like to open up questions from the floor. So if anyone has a question for George, again, the chat features at the bottom right-hand side of your screen. By all means, please type out your questions and I will read to George. I guess, George, a couple of questions. From my perspective, you know what to do to manage heart failure. If there were, if there was better coordination in the healthcare system, would we see declining mortality rates or are we doing everything we can do, we can just do it better? I'm not sure mortality would be the output that we would, I would hang my hat on. And that's because, can you hear me okay? Yeah, okay. And that's because, again, this is happening to people toward the end of life who are very frail and have multi-morbidity. And I think the main goal might be quality of life and keeping this table in the community and preventing re-hospitalizations. That might translate to lower mortality, but it would certainly most likely translate into a reduced rate of functional decline, greater likelihood of aging at home, but also more appropriate time to spend thinking about advanced care plans and engaging with patients to make sure that the goals are met throughout the course of their illness and really what we want to avoid are unnecessary hospitalizations. And once you get so frail that admission is not gonna help you dying at home, which is probably cheaper and more aligned with patient care goals. So mortality may no longer be that outcome. I suspect there might be lower mortality, but I think it's no longer the main outcome here. Right, okay. And you mentioned a few minutes ago about how the healthcare system operates on an old model, a reactionary model. Some people call it a sickness care system. You come in with a problem, they fix it, you go away. What, if we think about health prevention and promotion, what are the, I guess, some of the biggest messages that we could send out to people who are starting to come into middle age, starting to think about their health in terms of preventive activity. So I guess, better diet, exercise, et cetera. Anything else? I think it's to think about not, I think the mortality message may no longer apply. I remember seeing, well, it's important, right? But I remember seeing ads in the U.S. about cholesterol lowering pills and 55-year-old dad is playing football with the kids and he suddenly clutches his chest and drops dead. And sudden death is still a major issue, but I think in most people's minds, the hospitals are great, you call 911, you're on the cath lab table in about 80 minutes, you've got your stents, you go home the next day and all's good. And we have this assumption that we're cured. No, we just survived. And we still have this coronary disease. And I think what people might want to start thinking about is, and that's hard, are the future consequences of inactivity, of smoking, of poor diet. Not just that you'll die sooner, but you'll die with disability, you will die with dementia, you will die in a way that may not suit your goals of retirement. And so it's probably hard to get people to think that way, especially if the healthcare system does not allow for that kind of counseling to happen on a regular basis. You come in, you feel well, it's 10 minutes, no problem. And we just wait until the next crisis and the healthcare system is set up that way. And I think we need to start thinking about incentives that would allow Allied Health to spend more time with people with chronic disease and self-management. Self-management is not a pamphlet. Self-management is a very active relationship between a clinician and educator, usually pharmacist or nurse, practitioner or a nurse, and a person over time. Pamphlets don't really work well, but coaching works better. Right, and there's a question from CLSA, but just a follow-up, will our healthcare system ever evolve to the point where we can have that kind of individualized, personalized medicine? It can happen in some settings. So we've got a family health team with which I'm involved and they're getting there. But of course, family health team in Ontario has stopped funding these. And there's the reason for the lack of funding is because the overall evaluations were negative. When you go back to how family health teams began, the ministry forked over money and said, go hire some staff. There was no manual on who does what. And so some people fumbled and some people seized it and did a good job. So we need to look at those who did well and learn from them. What was the rest of the question? Which came into system change? And I think the ministry is gonna have to measure the right quality indicators from that perspective and provide incentives to the others to follow suit. Great. What measures, a question from CLSA, what measures would you recommend to measure vascular stiffness? So one of the most commonly used one would be pulseway velocity. So basically stiff vessels, transmits pressure waves more quickly. And you can essentially measure, get a good approach to the vascular stiffness by measuring the time between which at the crotch and say the femoral artery. And the shorter the delay between the two pulses, the more stiff your blood vessels are. So there's a variety of ways to do it. This is one of the more commonly done ones. Basically non-invasive. Great, thanks. Okay. Any other final questions? We have maybe time for one quick question. If so, and you can type fast before I stop talking, then we'll have a chance to ask. Otherwise, George, it was a very interesting presentation. And thank you very much for taking the time to enlighten us about this important issue today. And again, much appreciate it. Not at all. And so there was a question about the resources. So perhaps they can be posted with the slides later on, but there was one slide that had, a good place to go to would be the Community Cardiovascular Society Heart Failure Guideline Library, which is online. There's an update to the Heart Failure Guidelines coming up this spring. And it does address healthcare system issues from an integrated perspective. So hopefully that will help, that will resonate with some people. Great. Okay. So I see in the chat that our folks at CLSA will make sure that the resources slide is posted with the rest of your slides. And if you look in the chat feature, there's a link to the CLSA website where this talk and the slides will be posted next week. So the resource slide will be available. Again, thank you very much, George. And just to let everybody know, our next CLSA webinar is gonna be held May 24th at 12 noon Eastern daylight time. Philip St. John from the University of Manitoba is going to be presenting on multi-morbidity. So I think that meshes nicely with some of what George was talking about today. So we look forward to seeing you back May 24th. And thanks again, George. Thanks all of you for joining us today. And I wish you all a very great day and a nice spring. Take care, everyone.