 Namaste. I am Dr. A. Sharda here. Namaste. I am Dr. Priya Chinappa. We are both from the Department of Endocrinology and Diabetes from Manipal Hospital, Millers Road. Now, what about this heart failure? Because in heart failure also there is a lot of breathlessness and water retention, puffiness of a swelling of legs, etc. In patients who have diabetes and heart failure, any particular medications would you use? Yes, actually this heart failure is a very important complication of diabetes and I think it's often unrecognized and it's the most frequent reason for ER visits, this heart failure and breathlessness. Now, some of the medications that we discussed, the STLT2 inhibitors, really help patients with heart failure. These drugs, the way they work, they bypass the pancreas and the liver but they act on the kidney and they decrease the glucose reabsorption. So, glucose is excreted and along with that water. So, the water retention and everything actually comes down. So, these drugs are even indicated for heart failure and it is found to reduce the readmission rate of heart failure patients. That is very interesting. So, can these drugs be used in patients who have heart failure without diabetes? That's an excellent question and yes, because earlier we used to use these drugs only for diabetic patients but they have, they are indicated in patients with heart failure without diabetes because it helps in reducing the volume overload. You know, now that we've spoken about heart failure, some of these patients have had angioplasty and bypass surgeries with diabetes. So, how would we manage them? So, that is also a very important part because the patients who have diabetes are prone four times more to heart attacks than patients who do not have diabetes. So, we have to keep this in mind whenever we are seeing patients with diabetes. I am not looking just at the glucose control. That is an important part of my job but the most important part, we need to be alive to look after the diabetes. So, the heart problems are very important to look at the risk factors, family history of heart problems, smoking history, their blood pressure, their cholesterol that is called the ABC. We need to manage the A1Cs, the blood pressure and cholesterol and also look at the family history. So, these patients are supposed to have what is called atherosclerotic heart disease. As opposed to heart failure which is a pump failure of the heart, we have patients with atherosclerosis which is actually a pipe problem. The blood vessels which are in the heart and the brain which supply our legs, these are called the macrovascular problem. They all get blocked over the years of diabetes, blood pressure and high cholesterol and that is called atherosclerosis and for these patients especially in addition to diabetes control, blood pressure control, cholesterol control, we prefer the GLP1 receptor analogs which we have discussed in patients with obesity also because these molecules have shown that we can reduce the cardiovascular that is heart related mortality in the bypass patient or the angioplasty patient by about 22% and even the death due to all cause has also been shown to reduce in people with heart disease and diabetes. If the patient cannot tolerate or use the GLP1 receptor analog for any reason then we can also consider the SGLT2 inhibitors which we discussed earlier. This also has been shown to benefit these group of patients tremendously. So, I think what we are trying to say is you know once a diabetic patient walks into our clinic we need to first look at whether you know they need to lose weight or not and try to help them lose weight if lifestyle fails we give them certain medications like either GLP1 agonist, the injectable or the oral or SGLT2 which will help them lose weight and then once they develop certain complications we need to consider these medications again. Is that what you're trying to say? That is true and like I said we have lot of evidence and in the last decade we are looking at diabetic patient not at the sugar level and selecting the medicines all over the world we are looking at a patient with diabetes what are the other risk factors with the patient whether there is a kidney problem whether there is a heart problem or a heart failure and then trying to treat the patient as a whole. So, it is a lot of personalized medications and there is a big place in the armamentarium of diabetes first being metformin then we have weight neutral medicines like DPP4 inhibitors which actually increase our own endogenous GLP1 levels although they are not as effective as GLP1 receptor analogs especially in weight loss because they do weight neutrality but still they have a big place in the armamentarium So, each patient who comes to us needs personalized attention and looking at the entire spectrum of problems in the patient and not look at just the glucose which was the approach a couple of decades ago and this has taken a long way now and we all do risk management of the patient rather than just glucose control. Having said that diabetes control is of paramount importance but in addition other risk factors for heart disease, kidney problems, liver fatty liver especially and obesity needs to be managed to have a very healthy productive and long life. Thank you. Thank you.