 We get a couple of minutes Okay Okay, well, I think you guys did an awesome job Yeah, thanks. So, you know as an interventionally trained physician That's now just practicing Cardiology in the community one of the things that I hear is the age So we were talking about 65 year old not 85. There's a big difference, but 65 years old in Arizona is middle-aged. We're treating people with structural heart We're offering them valves. We have a lot of treatment options up until in their 90s really and if of course Frailty has to come in because we're not going to offer people that are bedbound. We want to see a quality of life So definitely we're going to look at the constellation and the and the quality of life But when you're talking about the cost in the United States of medical care, this is going to be Future this is what we're finding genetics AI making these diagnoses are going to be what's in front of us And so although the costs are astronomical now because of this one drug as we get more competition and Hopefully look Amazon is now providing insulin for $35. We may have companies that say, you know What we're going to go ahead and we're going to help these patients with these orphan diagnoses So I think that as we expand and go into the genes and the genetics we should be looking at all of these disease processes We never withhold dialysis. We give patients until they want it We ask them what they want as long as we're honest and give them all the risks and benefits of where we see them I don't think there's a problem making the diagnosis I agree that then the offering and seeing what we can do But that's where I think as a society we need to put pressure on the drug companies because we all know that's where the problems are It's they're trying to make money and they're doing it at the expense of lives of our families and our patients So I Completely agree with you. Dr. Agarwal, you know, I do a lot of geriatrics actually spend most of my career doing a lot of geriatrics You know, there's no way I can tell you that I have a 82-year-old guy from Sun City that comes to my office Which is in the West Valley a doctor. How are you doing? I'm playing three rounds of golf a week And you know when it comes to to like that patient, I would offer him Everything that I have I would treat that patient based on his functional status not on his, you know H H is just a number for that particular patient. I am not going to offer You know this life saving therapies of 225k a year to somebody that is in the nursing home That I know that has a life expectancy of six months to live on palliative care That's what we were pretty clear to make the point that we would just Carefully select and and this individuals that we are just considering, you know screening for the disease Which actually I think at the screening level is actually pretty inexpensive We were looking at the prices of free light chain and say it's like 150 bucks PYP scan I I tried to look at just I think it's 700 It's about the same as a stress test that we all do in our offices. You just have a different isotope And so all of us have the kit to do the testing. It just would be adding the isotope Yeah, you know, I think when we talk about treatment, you know I don't particularly think when I talk to the patient statin is the classical, right? I have 82 year old guys on statins Why even though the guidelines doesn't apply to patients over the age of 75 because actually I think it's unethical to give an 82 year old guy Statin and give him some my algeas, right? But I would still treat them based on their functional status if I now I want to just reduce their cardiovascular I think I think it's a risk-benefit ratio, you know when it comes I think we're all very frugal and very conscientious when we practice medicine And I think we want to offer the best for the patients when you look at the data on the families They actually have better quality of life, which is very important, right? Even when you're talking about the medicine and also reduce hospitalizations You know at the cost of hospitalization for heart failure, probably the most common DRG, you know for hospitalizations in the country So I think, you know, it's I feel a little warm when I talk about screening I really take your point very excellent presentation. Thank you You guys are too nice to debate. So our rebuttal is actually the same argument as you guys, okay? We did not know what they were going to say. We were not allowed to see their slides So I think at the end of the day, we all recognize that we have to screen the appropriate patient So we argue as you guys do that screening should not be geared towards only catching a rare disease in all patients You need to consider the appropriate risk factors Your screening should allow for the correct diagnosis of the underlying disease process as we've already said And if the patient screens positive for the disease, they need to have access to effective affordable and safe treatment options Um, and again screening should also take into account what matters most to the patient and their family And so Dr. Sauroff did an amazing job again educating the audience and I just wanted to kind of Reiterate and bring this point home that there are appropriate patients to screen and there's diagnostic clues to attr cardiomyopathy Very much based on our own history exam and then imaging as we've emphasized over and over again So again as a heart failure cardiologist, if I see a patient who has heart failure with preserved ejection fraction, you know, I'm Um getting my echocardiogram. I'm seeing what my ekg looks like again We've outlined kind of the low voltages in a thickened heart Um, you know patients who are not tolerating your conventional guideline directed medical therapy for heart failure Those neurological clues are key if you have a patient with lumbar stenosis carpal tunnel syndrome tendon rupture, etc And again as you go down this pathway, it'll be very important to make sure we're not overtreating or mistreating Hypertensive heart disease hypertrophic cardiomyopathy some of the other infiltrative cardiomyopathies The next several slides just focused on more of what's in the literature and diagnostic algorithms Um, it kind of really nicely spelled out From one of the CERC papers on the different pathways of cardiac amyloidosis. Oh, thank you um Let me get to that slide then So again, this can be a very confusing topic You know, I often have to remind myself to as a heart failure cardiologist like which type of amyloid am I dealing with? um And so this again is from a CERC paper and I really do encourage all of you to have this in your back pocket especially as there's more awareness for this disease process And you know, again, as dr. Soroff already said you want to really delineate the hematologic prevalent amyloidosis where we're talking about al amyloid versus the ttr amyloids and in the ttr amyloids You really want to make sure that you differentiate wild type From mutant because they're going to have you know genetic testing and familial sort of Implications that are going to be very important for our patients Let me see if I can go back to one of the slides Which one? Okay, um because there was another slide Um that I thought was important when I was putting this slide deck together and again There's so many different tests that are out there too and again It could be kind of confusing. Am I getting an echo? Am I getting an MRI? Am I doing this pyp scan that we keep talking about and that's where you can really utilize the help of You know your friendly cardiologists your friendly heart failure cardiologists your geriatricians Because as we learn more about the disease process these patients are complicated And we really do have to work together to make sure that we diagnose them appropriately and give them the treatment that they need I think you covered everything Ambulant to your point of sort of I I teach my fellows in residence What we're looking at life expectancy at this point. We're going to be looking at people 20 years More in regard to life expectancy And I think my point about screening everyone above the age of 65 is really that there is a big chunk which We really need to respect priorities what matters to them And understanding what is important to them and then make those decisions So that's really from us. Thank you. Thank you I want to make sure to Can you hear me now? No, okay So online zoom there's questions the same one as that's on the tabletop Please just answer those two questions and if you have feedback you can send those as well So, yeah, let's do um, is this mic on? Okay, um, yeah, let's do a little q and a for Um Five five minutes or so and then our judges will come back and give their feedback. So Um, go ahead and raise your hand and if you're online, uh, please post your question in the chat So do you have a question? So there were two questions. I'll just repeat it for online audience one question was um What's wrong with just starting with screening? To make a decision And the other question was how do you know that 4% is really the right percentage of patients? So let me defer to our panelists. So please Yeah, we we agree with your question excellent questions As I had said depending on which study you're reading right the prevalence is kind of variable So you're right in patients who are over 85. What's quoted 25 percent of patients Have some evidence of amyloid In their heart at autopsy So I think you're absolutely spot on now from an advanced heart failure cardiologist perspective like when we are screening that 90 year old It can bring some closure But again, there's a lot of fear with that too Of now you've been labeled with this diagnosis and depending on what their pre morbid Function was um, sometimes a psychological burden is extreme That's a great question. And again, I want to emphasize it's not really about age In no way I want to reflect that A 90 or a 85 or a 100 We really have to look at the person's frailty status and general well-being of the person when we are Deciding life and then the concept of life expectancy is important because When you're giving a treatment You have to understand the lack time to benefit That's another concept, right? If you are giving a treatment to a person who's gonna Benefit the person at the five month five year mark or the seven year mark And the life expectancy is three years Then are we doing justice? right um question to amber what is the usual time frame from The first clue that this could be amyloid cardiomyopathy and then the testing How long does that take? Yeah, I mean it depends on the center and it depends on the awareness At big centers, we might get patients who are in cardiogenic shock coming in with cardiac amyloidosis And it's too late on the other hand where there are centers of excellence for cardiac amyloidosis those patients may get Appropriately the tricky thing with that is, you know, the drug studies actually do show quick benefit Which drug we're talking about again at six months and the benefit may be persistent if you get those patients who are NYHA class two to three without severe comorbidities Yeah, so that's what I was going to say that the benefit of the drug therapies Unfolding of these proteins and actually allowing the nerves not to get the deposition Is so huge you can actually make a huge difference and 65 years old is really nothing in now We're living such a long life and the this this debate was 65 I get it for 85 But we're talking about middle-aged people who play golf and who are here in Arizona These tests these screening tests are not in the whole big realm We're screening everyone who comes in with shortness of breath with a CT scan to rule out pe on almost everybody We're getting we're we're doing a lot of testing and screening This should also be a screening test if you if you have the constellation of these symptoms And what you're finding on your labs and you have to actually think about it And that's what these educational programs are for so it's a question back here and then a question after that One of the one of the other considerations with screening Is if somebody presents With heart failure or with the cardiomyopathy And you think they have amyloid When you see them It's very difficult to know oftentimes whether they have wild type or hereditary without doing genetic testing So We also have to consider the children if they have them the offspring of of who you might be screening Because if somebody has hereditary TTR They they probably want to know that it's important for the kids to know that right so The only way that i've seen to reliably differentiate between Wild type and hereditary clinically at least have some sense of it is if there are significant neurological issues um Otherwise it's very difficult so Really i would advocate for Not only screening but the necessity of doing genetic testing particularly if they're offspring I think that's a critical factor in considering How far screening and then how far to screen in terms of genetic testing Okay, one more comment or question and then we'll let the judges present I want to just also point out that something that is not really life and death mortality or life expectancy Yes, it's debatable the frailty is the 65 or 85 the thing that I see a lot I'm advanced heart failure cardiologists my patient population. I'm a va cardiologist Are patients that most of the time they are in you know, they're 60s or 70s or 80s They are obese. They are smokers The creatinine is three. They have hypertension. They have shortness of breath. They come to see me And someone sometimes even in between and I thought about amyloid because it's okay. There was a lvh report on the echocardiogram and already they came up with a positive stress positive a pyps scam And they were thinking that okay. So why you know, this doctor is not treating my cardiac amyloid And my debate my presentation to them is that let's assume that you are positive Let's assume that that this is still is positive when your creatinine is 3.5 and you're hypertensive and your smoker treating your amyloid is not going to make you feel better and I think even it's not going to make you live longer because that's the two thing as a doctor I will do either are going to make you feel better or live longer You will die way before that You know the family is going to really work on you. So I think one of the things that I'm debating against Screening is that it's not about all this patient is going to die tomorrow. No this patient might be looking good Might have a five years of life expectancy or more But then has so many comorbidities You put the diagnosis of amyloid which is like fancier look Newer look more expensive medication on top of the something that you can easily treat So instead of stop smoking instead of let's give you some My fetipine to control your blood pressure or let's you know, make sure the nephrology is on board Oh, now we have amyloidosis diagnosis and we have to treat you for it Sometimes even I tell my patients, you know, I think that test is could be even a true positive But I'm not sure really I'm doing a service to you to even treat you for that Why don't you just go back come back and lose 20 pounds for me? Why don't you just quit smoking? Let's see what your shortness of breath look like because if I've treated six months from now Still you're at the same stage. So one of the things I also we need to emphasize Unless you're in a cardiogenic shock at the burned out heart Waiting for six months to treat in cardiac amyloidosis if someone is not having five types of hospitalizations And BMP is not like five thousand and troponin is not like two Waiting for six months not going to make that much of a difference. I would say one of the argument I have is that it just gives us False hope that by finding a diagnosis and treating that it's going to take we got to take care of the main problem Because you know, cardiac amyloidosis is famous for having given you shortness of breath But there are other things put potentially causing that No, no, I'm talking about when you have shortness of breath It's a lung cancer is different the cardiac amyloidosis Is not going to kill you in six months Unless you're in a very end stage, which probably you shouldn't even treat that because then in that case the family This actually defies the purpose because if you're stage four Giving you to family. This is kind of it's not really useful for you So if you're just having some symptom you think this is amyloid you have six months to think about go back and forth Treat the underlying cause I'm all for improving quality of life But I would say first let the patient walk more eat less quit smoking. Do they see what happens then go for next Screening gonna get a trouble There you go now you guys are talking and you're running out of time. So it's my turn now So this is it. This is exactly what we wanted. We wanted you guys to debate amongst yourself and you're doing This is fantastic. Are you guys having fun? Isn't that the team a fantastic team be even fantastic or You know, this is it right in a debate. This is exactly what happens, you know One team does good in something the other team does better than some other So we had some way to essentially quantify Some of these measures and so we looked at content the accuracy of the content we looked at the the use of Of sound logic and then in the delivery we looked at the voice the posture the gesture the The eye contact we looked at the effective use of time We looked at teamwork in your presentation and then in the quality of slide we looked at Whether they were too busy whether There was a you know good audio good visual and whether it's relevant research whether they've cited Beautifully in almost every slide that I saw for team a and then the analytical thinking. Oh my god Did they do a good job in terms of their ability to focus on the critical issues? In our lifetime across the board and you heard nimeth Kind of showing those beautiful two slides and dividing the old age into three different categories And I thought hey old age is just old age and here suddenly we are learning something brand new From him and then we suddenly we looked at the logical and the coherence and the and the development of the argument itself And and the smooth transition from one to the other And then all of this when we put it all together and both alexis and ivy scored it together We thought hey in one of these criteria team a did good the other one team b did good and the quality is like a team did Oh the analytical thing team b did good when we scored and actually measured it because what happened out there Will become no hold on we'll come to the rebuttal Now the rebuttal had separate scoring system And and and and both teams really had some very powerful thought process and and to to really summarize the rebuttal uh, I thought and both of us thought that That that susan you brought up something futuristic She talked about gene she talked about the gene editing that she talked about newer therapies that's coming We talked about hey at with time we know that all of these medications that cost us an arm and a leg Uh, we slowly now coming down with time and as you mentioned Oh, what if the famine is with $5,000 now would you screen more people right? So many of this is all related to all of that relation You brought that up beautifully and then when you did the rebuttal amber and and and limit You guys are fantastic in bringing up my favorite topic quality The quality adjusted life here. What a beautiful statistical terminology, you know The cost per quality was fantastically mentioned So in a sense it looks like my god, you did good. You did good There is debate going on even now at the end of all of this between the audience and the audience scored and we calculated that too And and we found Something very powerful something very important. So It is an african proverb When two elephants fight It is the ground that suffers Number two When you have to debate You have to convince the audience, but many times you have to do it by confusing the audience And I think both of you did that beautifully convince and confuse and convince again and thirdly As Woody Allen would say if he's standing right here He would say when you get to a crossroads Take it So we are at crossroads Why because the debate essentially was a topic that really didn't have one single answer yay or nay And with this debate you could go this way or you could go that way And both the sides essentially boiled down to saying that yes We had to use caution in the screen the elderly patients who have heart failure And in a sense we found the same thing the scoring system with all of this category Absolutely even and guess what the audience score was 50 50 So in a sense who benefited from this debate The patients are benefited and the audience have benefited and all of the people who have learned about the awareness and the knowledge Have benefited and I thank you Suzanne and Michael and I thank you amber and nimeth. I think it's fantastic Thank you for coming and thank you for really getting this together for all of us and supporting From the bottom of my heart and thanks to Sandesh for bringing us together Thank you so much so This includes our wonderful evening and now we're going to hand out the prizes to the the winners So You have your booty bags So thank you very much Thank you. We're really honored For your participation and your brilliant insights And I have to say it's it's amazing how far we've come you guys have really are great students of medicine. So Um, I really thank you for for pulling this off And we look forward to seeing the rest of you on november 8th for our next event Um, if you have any suggestions, uh, please let us know So thank you so much. So this ends our official, uh event, but happy to stick around Thank you Thank you And the questions were amazing, but you can't explain those heavy concepts in five minutes