 actually make the diagnosis. You don't want to miss it. Please welcome up our group that says no, you don't need to screen everyone over 65 with heart failure screening for cardiac amylidosis. Thank you. So I might sit if that's okay, because I took notes and I'm wearing heels and I don't know if I could move my slides and carry a microphone at the same time like Dr. Soroff. But what we'll start off by saying is thank you so much to Dr. Castro and Dr. Soroff. I think you guys did an amazing job laying out and educating the audience and us about cardiac amylidosis and why we should screen and the things that are concerning. I also noted that you put up hemodynamics to try to butter up your heart failure cardiologist. It's not gonna work. We're still gonna come after you guys. And then maybe you changed the prompt a little bit. So the prompt is that all elderly patients should or should not be screened for cardiac amylidosis. So we're gonna return to that question. We do have some disclosures. The views that we are presenting may or may not be our own. We might have been assigned this topic against our will. We are referring to wild type transdyretin amylidosis. And then we do have some disclosures that are not going to conflict with this talk. So we hear you loud and clear that we should screen patients who are over 65 with heart failure for cardiac amylidosis. But our argument is maybe we should screen with caution. Now some of the points that you pointed or you laid out about why we should screen everyone, we're gonna argue the opposite. So our team believes that amylidosis is a rare disease. It's often misdiagnosed. With some of the testing that's available, you have false positive and false negative results. This can lead to inappropriate treatment. We can have difficulty with drug approval, which can cause a psychological and financial burden for these patients. Treatment may not be cost effective. And the later this disease is diagnosed, the poorer the prognosis, again increasing potentially psychological and financial burdens on not just patients but their families. And you guys did not point out what are the patient's wishes. So maybe we'll focus a little bit on that as well. So I'd like to argue that amylidosis is a rare disease that in 2021, the American Heart Association estimated that the prevalence of heart failure is about six million patients. And 50% of these patients have heart failure with preserved ejection fraction. Now, depending on which study you're reading about one to 10, maybe closer to 4% of adults who are older than 60 with heft path, heart failure with preserved ejection fraction have ATTR cardiomyopathy. And the wild type is the most common type of amyloidosis. So we'll give you that. And there's the estimated prevalence of over 100,000 patients. We're not gonna touch too much on AL amyloid, but again, we're saying that wild type is more common than the mutant, which is more common than AL amyloidosis. So we still think this is a very rare disease, so screen with caution. Now, if you're screening for a rare disease, your screening tool has to consider the disease prevalence. The screening needs to allow for easy, impactful, and accurate diagnostic testing. Also, you need to be able to provide for affordable, safe, and effective treatment, okay? So Dr. Sauroff did an excellent job pointing out what cardiac amyloidosis can look like. Echocardiogram is very easy to attain. And for those of us who practice in this field, it's easily recognizable for us. However, I do like to argue that it might be difficult to diagnose for other individuals, and that's why we all work together as a team. And for those of us who work in cardiomyopathy clinics, there are several patients who come with a misdiagnosis on treatment for amyloidosis, and they have a totally different disease process that's not being treated. So this is from the Journal of Nuclear Medicine, where they looked at patients who perhaps look like they met criteria for screening for cardiac amyloidosis based on echocardiogram and heart failure symptoms. And of those patients, about 30% of them had planar imaging on PYP scan that was equivocal. Again, I've seen some patients who have equivocal scans, they're put on treatment, I don't know how it's approved through insurance, and then I have to be the one to say, you actually don't have this disease, and that can be challenging. So there's ways to obviously make our diagnostic tests more accurate, obviously. So the risks of inappropriate treatment, the cost of some of these drugs is astronomical. So there's that financial burden I keep talking about. These drugs often require prior authorization, so you're utilizing your staff to make sure you can get patients the treatment that they need. Now you've made the diagnosis, and you've talked to the patient and their family, but you've explained everything about it, and sorry we can't get you the drug because you don't have Medicare Part D or whatever Medicare part you need, and the drug company's not able to give you a substantial discount. On the other hand, we've had patients who've taken out substantial loans to try to pay for some of these medications. And then we'll kind of go through, is this really cost effective? How many years of life are we getting with these sorts of treatments? And again, I already emphasized that when we misdiagnose patients with amyloidosis, they might not receive the treatment for the underlying disease process. Now Sanjeev Shah did this amazing Markov model analysis to understand the cost of a drug such as Tefamidis, which is the most expensive cardiovascular drug that's ever been launched in the United States. So hooray, we have a treatment for TTR amyloidosis. That's amazing, but for some patients, it's cost prohibitive. And for this drug to actually make an impact in terms of cost effectiveness, instead of costing $225,000 every year, it would need to cost about $17,000. And again, unfortunately, we are diagnosing this disease very late. So we're screening the 80 year olds for amyloidosis because the diagnosis has been missed. Again, depending on which study you're reading, life expectancy is two to four years after diagnosis in untreated patients, and perhaps 5 to 5, 5.5 years in patients who are treated with the trans-threatened stabilizers. Important to note, the patients in these studies had NYHA class two to three symptoms. They were typically Caucasian, they were typically men. So as we're saying that everybody who's over 65 with heft pass should be screened, there is a certain patient population. We'll give you that. But we also need to keep in mind how these drugs are helping which patient population. So now that we have the medical perspective and we've considered the prevalence, the correct treatment diagnosis, early referral, psychological and financial burdens, we need to discuss the patient's comorbidities and wishes. Thank you so much Amber for giving this exhaustive review about this. Until yesterday, I didn't know much about amyloid and cardiomyopathy, so thank you Amber for enlightening me on this. And I have a really tough job as a geriatrician because when patients come to me and ask like, hey doc, what do you think I should do? What is your opinion? 65 is a pretty dynamic age group. I can imagine all of you can understand that. So 65 comes in different flavors, 65 to 75, 75 to 85, 85 to 100, 100 to 105, 105 to 110, 110 to 120, right? So it's a pretty big large group with different flavors attached to it. Now I'm gonna give you a little bit of a reflection here. So in your mind, try to imagine the last 85-year-old patient that you saw. The picture that comes to mind is someone who is frail, someone who is using a walker, someone who might be using a cane and might be dependent on a caregiver. I'm sure I'm right about this, right? But I'm gonna argue, I'm gonna say, are all 85-year-old patients frail older adults? And we used this word very loosely. We used the word frail very loosely. We should be using it with some evidence for sure. So I'm gonna give you a few concepts to just kind of understand, in the 65-year-old population, if you're doing a treatment, how do you decide if this treatment is gonna be beneficial for this person? Or if it is not gonna be beneficial for this person, if you remove the disease from there and use age and maybe frailty as a concept? So that is what I wanna emphasize here. So on this picture that you see up there, I could, if we take age out of the picture, let's say all 65-year-old patients, you divide them into maybe three categories. The first category on your left is the person who does not have any chronic medical issues. He's really fit. He is the 85-year-old who is climbing Mount Lemmon. He's going on a hike. He is like, hey, guys, what matters to me is that I can drive, I can get to Mount Lemmon tomorrow, right? So that's your 85-year-old there. And then on the extreme right, you have your patient who has maybe a limited life expectancy of one to two years, right? This is a person who is severely frail and has life-limiting illness and he has a life expectancy of one to two years. And this is a person that you would think about palliative care options or symptom management of disease and stuff. I think these one, these groups are the two easy groups, right? Because you have the answer. For the first group, you want to do what is right, like guideline-based therapy, evidence-based care. You want to do it just like you would do for a younger adult, right? So there is no argument about it. And for the last group also, I think there is no argument like, hey, I mean like maybe it might not help you if we start treating you with or checking you for amyloid cardiomyopathy, right? But there is a big churn right there in the middle, right? Which we don't know where the evidence applies to. That's the uncertain group right there. So they have some comorbids, they have some frailty going on and they might have some challenges going on psychosocially, financially, which are impacting their life in a way, right? So let's move forward to the next slide. So 85-year-old guy who has been living at home, he is using a walker and he has congestive heart failure and he is able to get to the mailbox with a lot of difficulty. So I've used this tool called e-prognosis here. And e-prognosis, if you use this tool, it can actually tell you the mortality risk, the ADL disability and the walking disability risk. So for our patient here, his mortality risk compared to an average patient is about 98% at the five-year mark. And the ADL disability risk is 51%, which is higher than average and his walking disability risk is about 26% higher than average. In this person, I would be very careful even when I'm approaching the topic about should I check for amyloid angiopathy, even though he might be having symptoms. Why? Because I want to know what is important to him and that is something you can use using this tool called patient priorities care. So we want to know what his priorities are. His priorities might be like, hey, I want to be at home, spend as much time as possible with my family, be able to control my symptoms. I'm not looking for that $5,000 testing and going to the cardiologist's office, primary care office, hematology office five times a month or maybe five times in three months or so. I would rather spend that time at home and I don't have any family to take care of me who can take me there. And I can't afford the $50,000 I have to spend for the drug. So you want to know their patient priorities at that point. And this graphic, kind of this website will give you information on how to make that possible. So it basically spits out this information. It'll tell you doing activities with family and friends is what matters to him. And it'll also tell you what tasks are important to him and what burdens some treatments he would not want to continue and would want to forego some of those treatments. So that's one way of looking at it. So my point here is 65-odd population comes in various flavors. Don't use age as your only marker. Think about frailty. Use evidence-based tools to determine what is right for them. You have a big chunk in the middle, which really needs your help to make the right decision, keeping their priorities in mind. Remember? I think you said it best. That's a mic drop.