right good morning thanks for coming everybody um it's my pleasure to introduce Dr Danny hidano uh I've known her as uh a one of my fellows for the past three years um but sort of jumped to ahead of her CV she's going to join us at Harborview and I'm so excited uh Dr hidano um another connection that have is that she uh got her Bachelor's in bioengineering from University of Washington um a little known fact about me is that I was one of the very first students in BIO undergrad degree in bioengineering 10 years before her so it was very nice to see sort of how the program has flourished and generated wonderful young women who go into stem and go on to do great things uh she stayed here for her medical school and then went to University of California San Francisco for her residency and we were very lucky to have her come back for for her uh fellowship with us and um she's uh been involved um with um her uh research and her interest in math um induc cardiomyopathy and is very much interested in working with sort of our underserved population here in the harbor view and is I know going looking forward to working with the community heart failure program and just we're just so very lucky to have her here with us and I'm excited to hear about meth indued cardiomyopathy thank you awesome good morning everyone um thank you so much for being here in person and on Zoom Ruchi thank you so much for that very kind introduction um I have a lot of slides so I'm gonna go ahead and jump in and get started um unless you have burning questions if you can save your questions to the end um I should have a few minutes left over um so today I'll be presenting on methamphetamine Associated cardiomyopathy um it there is I just want to emphasize that there's a huge overlap between what we do in cardiology and substance use um if you treat any of these conditions which all of us do in cardiology then I think substance use is very relevant to all of you um whether you know as disease uh risk factors disease modifiers or um sometimes uh when you're when you're treating these conditions having to take into account um someone's substance use um is very important in the ultimate success of of treating that patient um this is a huge scope and so I really just want to spend the next hour focusing specifically on methampetamine Associated cardiomyopathy um I'm going to run through sort of the history of the rise of the methamphetamine epidemic um and talk a little bit about the epidemiology of meth Associated cardiomyopathy um I also will next talk about how we think meth causes uh damage to the heart some predictors for potential reversibility um touch on current management strategies and then share some exciting um updates on the horizon I'm going to start with a patient case um this is a 45-year-old man uh who presents with two weeks of new onset worsening lower extremity swelling and shortness of breath concerning for heart failure this patient has a past medical history that's notable for opiate use disorder and prior GI bleed um he is unhoused he's currently living on the streets in Seattle in a tent um and has for many years and endorses daily IV heroin and IV methamphetamine use um this is his initial Echo when he comes to the hospital um you can see that he's got biventricular dilation and a pretty severely reduced uh left-sided ejection PR at 22% his right ventricle is also at least mildly uh depressed as a part of new heart filer workup he does get a coronary angiogram um that is without any obstructive coronary disease I think what's most notable is the amount that they have to pan to see his entire heart just as a reflection of how dilated he is um they perform the rest of the serologic workout for heart failure and that also is negative and he's ultimately diagnosed with methampetamine Associated cardiomyopathy um during the hospital course the patient was also diagnosed with merab acteria he's ultimately discharged to respit for IV antibiotics while there he does really well and expresses a desire to stop all substance use with assistance he was able to take all of his cardiac medications the notable cardiac meds being linil 10 mopol 25 and l620 um and he was attending his Clinic appointments um fortunately rbit was also able to help get him set up with permanent Supportive Housing and so when he was um discharged from rbit um he had a place to live unfortunately once he left he was on his own and he was unable to manage his own medications despite best intentions um this led to recurrent hospitalizations there were at least three for heart failure and additional hospitalizations for GI bleeds and sepsis um during this time he was also unable to cut back on either meth or heroin and a year later his repeat Echo showed an EF drop further to 16% and provider notes start to mention um maybe considering hospice at this time um I present this patient's case because I think many of us um in the audience have encountered patients who are in similar situations as this gentleman um and I it's really motivated me to learn more about this topic and I'm excited to um share with you all what I've learned um and we'll be returning to this patient's case near the end of my presentation so moving into um kind of the history that I find very fascinating about the rise of the current meth epidemic that we're seeing today um this is kind of a busy slide but is highlighting the timeline of how amphetamines were initially discovered and marketed um edrin is a naturally derived substance that is uh found in the edra plant it's been used for hundreds or thousands of years by traditional Chinese medicine and you can see that the structure of ephedrin is actually very similar to a lot of the now human synthesized amphetamines and methamphetamines that we have today so in the late 1800s there were Japanese and Romanian scientists that um isolated edrin made the first uh amphetamine and methamphetamine methamphetamine um then in the 1920s uh a lot of scientists were studying amphetamine they noticed that it increased heart rate and blood pressure that it caused Bronco or Bronco dilation and Vaso constriction of the nasal mucosa beds so of course um pharmaceutical companies jumped on that and in 1932 um an American pharmaceutical company U marketed the first amphetamine inhaler um termed benzidine this was used for asthma hay fever nasal congestion um by 1940 there was then amphetamine tablets that were brought to Market these were um prescribed for 88 HD and narcolepsy and in the same year um there were methamphetamine tablets that were being marketed as well called methedrine during World War II amphetamines and methamphetamines were widely distributed to troops both on the a uh axis and Allied Forces so um this was used to increase alertness um decrease fatigue and decrease appetite of um the military forces um following World War II in the 1950s and 60s um I was not previously aware of this but there was very wide use of methamphetamine um people were using it like every day people were using meth for all sorts of things to promote mood and attention to increase wakefulness to promote weight loss um it was being uh marketed to to people like students athletes um Long Haul truck drivers Etc um it was also during this time when use really took off and people were really noticing the euphoric and kind of addictive properties um of amphetamines and methamphetamine um pictured there are some ads that were um targeted at the general public um abrol was actually a 50/50% mix of amphetamines and methamphetamine um by the late 1950s um there start to be uh signals that people are developing tolerance and starting to show signs of addiction and Mis misuse of these uh drugs um the FDA um sort of reacts to to to this growing issue um that's becoming more apparent by starting to require a prescription for all amphetamines and methamphetamines um then in the 70s they make uh these substances a controlled substance um and then by 1996 they're really trying to control the precursors uh over the counter really edrin and pseudo fedrin that are commonly found in cold medicines even today um they're trying to control the the sale of those to try and prevent um on on goinging uh elicit production um what you can see in this graph here is these are the um meth lab seizures in the US and you can see that um by the late or by the early 2000s there's really a peak and then a fall um as a result of all of these regulations so they were successful in kind of stunting the amount of domestic um methamphetamine production in the US however um coinciding with this same point in time you can start to see that more meth is then being seized at the US Mexico border um which really demonstrates that there was a shift in terms of where the meth in this country is currently coming from and a lot of it is still being illegally imported um by 2006 the United Nations World drug report um declares that meth is the most abused hard drug on Earth the US and Mexico Are Not Alone In experiencing this problem um you can see that all over the world there are sort of pockets of um uh countries that have high prevalence of methamphetamine and amphetamine use as well the US is the highest at 3.3% back in 2018 um but you can see that parts of Central America Eastern Europe southeast Asia and Australia are other places where there's extremely high meth use um since this since that time so from the early 2000s fast forward to today this is the most recent data that I can find in terms of the the prevalence in the US so this was a national survey conducted in 2022 they surveyed um people who were 12 and older and asked if they had used any CNS stimulants within the last year um one in 30 people responded Yes um you can see that most uh endorsed cocaine use at 5.3 million um 4.3 million were misuse of a prescription stimulant and then 2.7 million um endorsed methew um of the 2.7 1 8 million people um reported a use disorder and I think um what's uh notable is that this survey did not um survey either um homeless or incarcerated individuals and so these numbers may actually be much higher um I want to mention that methamphetamine adversely affects every organ system this was a pet scan that was done they um tagged methamphetamine and then administered it to this patient and and imaged where in the body um methamphetamine goes and you can see that it's taken up by um a bunch of different organs I think historically we've focused a lot on the CNS and the Heart side effects mainly because those can cause immediately life-threatening conditions such as stroke um hypertensive emergency heart failure and shock um life-threatening arrhythmias and coronary vasospasm which presents like ACS and chest pain um but there are a number of other um maybe lesser known effects of meth that can be equally detrimental over the long term um as you might expect with the growing um meth methamphetamine epidemic um you it it also um uh the hospitalizations that are related to amphetamines have also sort of followed that you can see that um this is based on us data and you can see here on the West Coast that we really have the highest prevalence of amphetamine related hospitalizations focusing specifically on meth related heart failure um this graph really shows um the number of methamphetamine uh heart failure hospitalizations per 1,000 heart failure hospitalizations um you can see in the darker red color on the west coast where we are located that we have an extremely high prevalence of meth related heart failure as compared to other parts of the country um our rate is 500 times greater than that um that is seen in new in the new England area and this is data from um 2020 um similar to us on the west coast California a lot of uh Studies have come out of um this area and what they've highlighted is that from In the 10year period from 2008 to 2018 meth related heart failure admissions have increased 600% um now accounting for 8% of all heart failure hospitalizations um similarly that from the same study in 2018 um they estimated that California spent almost $400 million on meth heart failure to back up for just a minute um to Define what meth Associated cardiomyopathy is you know there's no formal diagnostic criteria but from the research studies and from what we um what I've seen clinically we tend to diagnose someone with meth Associated cardiomyopathy if they have heart failure with a history of methamphetamine use and exclusion of other common causes such as es schic disease um the patient population that's typically affected are younger than what you would see for an es schic uh mediated heart failure patient um in the studies that I saw the onset of heart failure tends to be 10 to 20 years younger um for whatever reason there's also a very strong male predominance of meth related heart failure the cohorts um site anywhere from 60 to 93% of um the meth heart failure cohorts being male um these patients also have um more prevalence of socioeconomic disparity and so you can see that a lot of patients are on um uh state sponsored insurance or uninsured um a lot of our patients are also um dealing with housing instability and there's a higher prevalence of psychiatric disorders and other comorbid substance use but lower risk or lower rates of traditional risk factors um that we're used to seeing associated with heart failure the typical Echo findings are are noted here so starting uh on the left you can see that U meth related heart failure typically will present with pretty severe left-sided dilation and systolic dysfunction Um this can progress to then see left atrial enlargement and then if more severe you'll also see right-sided involvement which can be both dilation and dysfunction um the next image over in addition to the first image both show um examples of intracardiac thrombi um from The Echoes that I've seen um at Harbor View I mean I think that it is true that these intracardiac thrombi are actually um diagnosed pretty commonly in this patient population um uh moving on um functional Mr and TR are also common and that's just secondary to the ventricular dilation that we typically see pulmonary hypertension um is also something that can either be due to left-sided failure or there's also a toxin mediated primary pH that we can um that can result from meth um and then lastly um if someone is not presenting more as the four chamber dilation and dysfunction but is presenting more acutely occasionally you'll see actually more of a stress cardiomyopathy pattern um and uh I'll get in a little more to that in a little bit um what I find interesting about meth heart failure is that um variable onset in terms of when patients start using and from the time that they develop heart failure symptoms on average from what I saw the the time is about five years um but 20% will develop heart failure within one year um as you might imagine uh there's a lot of um uh different um features of use that might uh affect this such as route of use um potency of the drug um frequency and duration of use there may also be genetic underlying factors such as people have brought up whether or not there might be a two-hit hypothesis with someone who has a pathologic um Gene that might predispose them to cardiomyopathy and then meth is the second hit um I also mentioned the sex predominance of this uh condition primarily affecting men which we don't fully understand um and then various comorbidities so traditional cardiac risk factors certainly could affect the timing of onset of when someone's going to develop part failure and we also know that alcohol when used in conjunction with methamphetamine um is particularly toxic to the heart um so the way in which meth causes damage to the heart um a lot of people have um cited the sympathetic or catacol amine um surge that is uh a result of methamphetamine use um the euphoric effects can often decline after a few hours um but the sympathetic effects of methamphetamine May persist much longer and so this can lead to kind of repetitive use um and stacking of the cardiovascular effects binge use in particular which is continuous use for multiple days is thought to be particularly detrimental to the heart and all of these catacol Mees can cause a variety of complications um in the heart particularly demand esmia from the elevated heart rate and blood pressure um coronary vasospasm arrhythmias um stress cardiomyopathy and with repetitive insult um all of these things can lead to fibrosis over time um we also know that even with trying to control for sympathetic overdrive that there is still evidence of fibrosis in rodent models and so there's also a theory that meth is also directly toxic to myocytes um this is one of the rodent models that demonstrated really nicely um the the time dependent um cardiac muscle damage that's induced by methamphetamine so they they took 30 control mice and 30 mice that were injected with subcutaneous methampetamine every day um you can see at Baseline or the control mice that's what normal um um myocardium should look like and even after just 14 days you can start to see that there's evidence of myosite degeneration and infiltration of inflammatory cells and by 56 days you can see that there's pretty clear um uh like contraction bands and evidence of fibrosis um in human studies these are endoc endomyocardial biopsies that are taken from three different patients that reported um different durations of meth use and similar to the the mouse model you can see that with longer reported um methamphetamine use you can see just more um more fibrosis and more myosite disarray and so this study um looked at actually 30 different endomyocardial biopsies and they were able to conclude that longer duration of methus was associated with more fibrosis and was statistically significant in their study the same study also concluded that fibrosis extent was independently associated with Improvement in cardiac function after the cation of methio so you might next be wondering what about cardiac MRI as a predictor of um you know or as an assessment of to see how much fibrosis someone might have um the answer is yes we do see patients quite frequently have LGE on their cardiac this was a study of about 30 patients as well it was retrospective they just looked at any meth cardiomyopathy patients who had undergone an MRI um and they reported that 76% of patients had LGE but that the the pattern of LGE was quite variable um I would say 60% of patients had um LGE in the midwall which the authors theorized was maybe due to chronic inflammation and maybe repetitive stress whereas the subendocardial and transmural LGE um maybe was more related to um eskema leading to infar from potentially vasospasm um they did rule out obstructive coronary disease in all of these patients and so um I think that's how they concluded that vasospasm might be um might explain some of these LGE patterns um going back to that first study that I showed you with the endom myocardial biopsies this was uh they followed patients longitudinally over time and after a couple years they um brought patients back and asked them if they had were successful in stopping meth use or not and based on that they showed that in patients who reported abstinence from methamphetamine were able to recover their ejection fraction to 43% as compared to people who continued methamphetamine their EF stayed around 21% similarly we saw changes of positive remodeling you can see that their LV and diastolic diameters were also um smaller um compared to the patients who continued um um additionally this study concluded that patients when they came back had lower um nyha class and also lower risk of death um and rehospitalization from heart failure um so so far we've discussed that some features that may predict reversibility include extent of myocardial fibrosis and also methampetamine cessation um other findings that may predict uh reversibility include that stress cardiomyopathy pattern that I mentioned there are a few Cas series that showed um that five patients all normalized their EF after 6 weeks um when they presented with this kind of pattern um on Echo for patients who are presenting more with that chronic cardiomyopathy like picture the smaller your chamber sizes um the more likely you were to recover and I think intuitively that makes a lot of sense it means that you have less uh remodeling at that point um and then I would say that the data on LGE is just quite Limited at this point have only a single case report of a patient who did not have LGE who went on to recover and then a very small case series of six patients where two of them were lost to followup half of them had LGE and half of them didn't but I think the recovery um was pretty mixed and so um not to say that there's not potential there I think that there is but I think we just need more studies um looking at the sort of heterogeneous nature of LGE and not just using it as kind of a binary yes no LGE um so I'm going to jump ahead to the management of meth Associated cardiomyopathy I wanted to start by first talking about um treatment of the underlying substance use disorder um I want to First emphasize that I think we should all be striving to provide trauma informed care for those of you who haven't heard of this term before it's mainly about understanding how an individual's past and and present trauma affects their health directly in addition to how it affects their relation ships with other people and their interactions with the healthare system I think it's important to consistently check in and try and be aware of your own subconscious biases around substance use and mental health and then lastly I find it helpful to think about substance use just as you would any other chronic medical condition that requires a formal diagnosis and formal treatment by the medical system um I think in along those same that same vein I think it's um helpful to try and understand the reasons why people use all three of these quotes were taken from a survey um done here at the University of Washington and I think the general theme is that um people are are trying to do their best and are trying to do what's in the best interest for themselves and oftentimes are driven to use substances either to prevent something negative whether it's self- treatment of emotional pain or physical pain or to prevent like the horrendous symptoms that come with withdrawal um or they're using for a very sort of practical and legitimate reason a lot of our patients are dealing with housing insecurity and many patients endorse using methamphetamine so that they can stay up throughout the night so all of their belongings don't get stolen or so they don't get assaulted um I think as cardiologists we are all able to assess someone's Readiness for change I think many of us are familiar with sort of the six stages of change that you may have heard in the cont text of motivational interviewing and it's just a spectrum that is dynamic and patients um Can can move up and down this spectrum and that's normal and okay but I think what I want to stress is that when we're diagnosing patients in the hospital with really bad heart failure that specific moment is not always um the moment in which patients can realistically stop methampetamine um immediately and I think that cessation is not always a realistic goal and that that's okay I think meeting patients where they're at is incredibly important and for even for patients who are earlier um on the Readiness for change I think we can still Target things like harm reduction making sure they have access to clean needles to offer um resources for them to obtain fenyl test strips which is a way they can test their methamphetamine for contamination with fentanyl to try and prevent accidental overdose um and then to also always just offer a Nar can prescription for these patients I think if people are further along and are ready uh to enact change I think that we can also help facilitate referrals to addiction medicine at this point um another Paradigm that I want to kind of turn on its head I think a lot of times we focus on the fact that we don't have FDA approved medications uh to treat stimulant use disorder the reality is is is that is true but we also do have a lot of other kind of Behavioral therapies that are quite effective for treatment of stimulate use disorder for patients who are motivated um and so I think I've just listed a bunch of things here that um when we refer our patients to addiction medicine um maybe strategies that they could use um for our patients the one that I'm most excited about is contingency management um for those of you who haven't heard what this is it's a really exciting um uh way to kind of try and modify behavior um it is very effective in stimulate use disorder in fact the studies that I saw um or meta analysis that I read said that the number needed to treat to get one patient to stop using meth may be as low as four um and this strategy effectively is um using motivational incentives to reinforce an intended behavior and I'll give an example um contingency management was directly applied to meth heart failure um they were doing this at UCSF when I was a resident there at San Francisco General which is very similar um to our Harbor View Hospital they were piloting something called the heart plus clinic this was a co-management clinic between Cardiology and addiction medicine the program ran for 12 weeks and their contingency management was set up in in the way that they would give patients um grocery store gift cards in exchange for Clinic attendance and negative drug screens um I know this protocol is is kind of small text but in case you wanted to reference it later to summarize um you know this was the Fishbowl that they use there's 500 pieces of paper in there half of them have a positive affirmation like good job keep going keep it up written on it whereas the other half had some sort of monetary value written on there that could be exchanged for one of the grocery uh grocery store gift cards 42% had a $5 gift card 8% were $10 and point2 was $100 and every time a patient came into Clinic they would get to draw um uh out of the Fishbowl additionally if they had a negative urine drug screen they would get an additional draw from the Fishbowl and for every time they came back to Clinic without missing an appointment they were able to draw more and more um out of the Fishbowl and so in this way was reinforcing um the positive behaviors that of coming to Clinic um and and submitting a clean urine uh drug screen if they had missed an appointment then the count would just reset um back to the beginning um and their results were really exciting This was um uh data from both their pilot study and then their subsequent follow-up cohort um they found that 100% of patients reported decreased stimulant use just over this 12we program and three patients or 14% were able to stop completely and again this was a very short-term um pilot study but I think those those results are very impressive they also showed that engagement in clinic improved dramatically so um they were able to achieve almost an 80% Clinic attendance rate um and Clinic engagement increased fivefold they also were being co-managed by a cardiologist and for their report all of patients reached Max tolerated gdmt just over the course of these three months um and then lastly acute care utilization was also reduced by 53% I think perhaps what's most striking is the cost effectiveness of this program it was only um a150 per patient per day in total over the 12 weeks the patients received about $1,700 in gift cards individual participants there was quite a range in terms of the amount that patients got but the median was only $150 and I think when you put that in the context of how much money our country spends on heart failure um this is really just a very small drop in a very large bucket um uh the US spends an estimated you know 39 to 60 billion doar on heart failure every year um with hospitalizations accounting for the vast majority of that cost an average hospitalization in the US is anywhere from 10,000 to $177,000 and so doing the math you can see that if we could use contingency management or some of these other strategies to reduce one or two hospitalizations over the course of the year you've paid for contingency management for like 10 years um I think what's really exciting is that from what I read uh contingency management has been available at the VA hospital since 2011 and it's been very successfully utilized there for a variety of substance use disorders not just stimulants um and and just kind of Googling in the news I I saw that uh Washington State Medicaid is now the second state after California to approve contingency management um I haven't seen this widely rolled out yet I think there needs to be systems and Clinics built um to sort of um accommodate um more contingency management but I think this is something really exciting on the horizon that I hope we will see more of um so we just talked about um treatment of substance use disorder so to summarize trauma-informed care is very important assessing someone's Readiness for Change and getting them connected with the appropriate resources and then um getting really excited about contingency management and sharing that with our patients um as a potential strategy down the road to move on next to heart failure management um uh this is more within our wheelhouses cardiologist um but I think I wanted to stress that it's the same four pillars of heart failure management that we would use for any of our other heft patients I would say that there's limited literature on specifically using gdmt in meth Associated cardiomyopathy specifically but I think it goes to reason that once you've developed pretty severe systolic dysfunction that there's this presumed benefit that you um would still see from gdmt from blocking the same maladaptive neural hormonal Pathways that we see in hurt failure so beta blockers Ras Inhibitors aldosterone antagonist and sglt2 Inhibitors are all um very important to try and get on board um I comb through all of the literature and the only four studies that I could find that reported kind of rates of gdmt utilization are listed here um you can see that beta blockers um are probably the the the category in which we are prescribing the most um I want to sort of debunk the myth of this uh that the dangers of beta blockers in active stimulant use I think this came up in the early 1990s as as kind of like case reports here and there this has been studied very extensively and there's been a lot of meta analyses done and this um just has not been consistently demonstrated so I want to emphasize that beta blockers can and should be used in meth related heart failure when there's a class one indication to do so um moving on to Aces and arbs again no specific studies is looking specifically at these agents in meth cardiomyopathy and certainly none of them have reported um rates of entresto yet and then Mas are perhaps our worst category um with the lowest utilization and I wonder if that's just due to trying to prioritize the two first medication classes with really the most um efficacy and maybe people are also worried about the risk of hyper calmia if these patients were lost to follow up but either way I think we can do better um I want to also highlight that a current Gap in knowledge is that no Studies have really looked at gdmt as an independent um predictor of clinical outcomes they've all been kind of Under the Umbrella of meth cessation um similarly people haven't looked um more granularly at like the specific doses or adherence as it relates to clinical outcomes and so that was really um the the foundation of what um what we were hoping to look at with our registry um so I'm making a registry of meth Associated cardiopathy patients with the help of Cooper and um who's one of the internal medicine residents here we collected um new onset heart failure due to meth over the last few years within our hospital system we've found 88 patients and you can see our um uh utilization of gdmt and how it Stacks up against some of these other related cohorts and because we were looking um at a more recent uh more recent cohort we also recorded um rates of Ino and sglt2 Inhibitors and you can see that the rates of these are also very very low um the vast majority of our patients are insured with Medicaid and I just want to emphasize that Medicaid in Washington state does actually pay for both Ino and impago in and so we really should be trying to get these numbers um better this is more granular data also from our same registry um you can see that within each medication class patients were most likely to be discharged on mopol lysil spirolactone and impago in all at pretty modest doses um but that there's a lot of patients who are still being discharged with new onset heart failure who are not on any of these agents and I should mention that all of our heart failure um that our heart failure patients are all EF less than 40 so really have indications for all four of these medication classes and the first aim of our study is to really describe kind of Provider prescribing patterns and to identify areas in which we could be doing better um next um our we're hoping to calculate an individual gdmt score for each patient so by drug class um each individual could get you know a range of points depending on what percent of the target dose um they are on um for each individual patient the gdm scores across all the drug classes are summed up to get one number and you can see that that's what's graphed on the right hand side of the screen and this is really just a way to try and assess you know an individual's quality of gdmt um and you can see that most of the patients who were discharged um with a new diagnosis of heart failure in our system had gdmt scores less than five whereas very few had gdmt scores of 10 or higher um and to give you a sense of what this gdmt regimen might look like someone with a score of two is someone who's just being discharged on lysen April 5 whereas someone with a score of 15 is on the lowest dose of entresto mopol 25 Spyro 25 and EG 10 and I put that up there just to say that that's not an unreasonable regimen that we could get our patients to even during the first hospitalization so I think this will help identify um that we can do that we can do better um the next steps in our study is going to be to correlate those gdmt scores with clinical end points such as heart failure hospitalizations um change in ejection fraction and mortality um we hope to calculate similar data for a a control group to use as a comparator um and then we also collected um serial uh medication data to to be able to calculate a second gdmt score and follow up and that's going to be based on prescription dispensing records that are available in Epic um and I think the reason for doing that is we know that just having an active prescription at discharge doesn't mean that the patient ends up picking up that medicine in in the real world and so this is just one step closer at maybe trying to estimate um real world medication adherence um kind of pivoting back to heart failure management um uh we've just talked about gdmt now looking our at primary prevention icds um probably not surprising to any of you but there is a very low reported prevalence of icds in meth Associated cardiomyopathy and patients who meet the traditional indications um there were only two studies that cited the the prevalence of icds and it's somewhere between 15 and 33% um and what I wanted to emphasize is that um patients who present with Cardiac Arrest due to stimulant use disorder um 24% of them are presenting initially with a shockable rhythm and so it just begs the question you know should would patients benefit from having an ICD um and this is in contrast to patients who present with opiate related overdose Cardiac Arrest um they're very rarely presenting with a shockable rhythm because their um uh overdose is more likely related to like hypoventilation um leading to pea whereas with stimulant use perhaps this is more of like a vasospasm or a schic um kind of ideology um so to just summarize the gaps in knowledge you know I think as I mentioned um gdmt in the association with clinical Improvement has not been studied the effect of gdmt in patients who continue to use meth also has not um fully been evaluated and so this is really what we're hoping to address with our registry and then primary prevention icds really not sure if we should be applying the same criteria to um this population particularly I want to highlight that you know I did share with you that they have potential to recover with cessation and gdmt and so you know at what point do you pull the trigger and say this person would benefit from an ICD similarly um we have to take into account that this patient population may be at higher risk of harm from devices whether that's inappropriate shocks repetitive shocks or infection particularly with transvenous devices um so that was heart failure management I think the main takeaway is that we should be getting all of our patients on guideline directed medical therapy um moving on to the last category so treatment of intracardiac thrombi this is a short section uh because we don't know too much about this but I've shown you now like some pretty impressive um Echoes of patients with very large um LV thrombi the rate of intracardiac thrombi may be as high as 33% and people have theorized that um the catacol amine surge may lead to sort of a prothrombic state and combination with really severe cardiac dysfunction that kind of leads to this High prevalence of LV thrombi um we frequently diagnose this with um Echo I think very low threshold to use contrast um because finding an LV thrombus will definitely change management for the patient um Additionally you can use MRI or CT and what's been recommended is quote unquote long-term anti-coagulation but there's not really any um further guidance on how long that is um this Echo uh the top two images are from admission this is all the same patient um the top two are from admission where you can see that huge mural thrombus that's kind of hugging the septum going down towards the Apex and then after just seven days of Warring you can see that the while the thrombus is smaller it also looks very terrifying and is kind of prolapsing in and out of the lvot and is at risk of embolizing um clinically there was not signs that this embolized to the brain or any parts of the body um and it it pretty quickly um dissolved which is very impressive um but I think gaps remaining in this area remain like how long do we treat these patients with anti-coagulation um are there patients who would benefit from prophylactic anti-coagulation given the really high prevalence that we're seeing um are doax better than warrin in this area particularly if compliance might be better with doax um and then what is their risk of embolism okay so that wraps up the man section um I wanted to end this talk by um sharing some really exciting updates that are happening at Harbor viiew um I'm going to go through each of these one by one um the first is the Harborview Community heart failure program this is run by Jamie and Kate who are both here today um they are the founders of this program and really worked tirelessly to get funding and to to really lift this off the ground um this program is a very intensive and longitudinal um community based program where Kate and Jamie go out and meet patients um in the places that they live or wherever they prefer to get their care and they're able to do things like medication management um lab draws and patient education um and really have been um incredible I'll share some pilot data with you in just a second but um the referral criteria for this program are hefu with an EF less than 40% um and at least one admission in the last 6 months um evidence of difficulty accessing outpatient care and um uh experiencing adverse social determinance of Health um this is data that they shared with me from their pilot program of the first 10 patients that they enrolled you can see that before the pilot in the one year and two years before um there were a a high utilization of acute care including Admissions and er visits after the pilot program you can see that every single patient had reduction um some quite dramatically if you look at patient 8 and patient 10 you can see like very dramatic um reductions in the in the acute care utilization and this is not just for heart failure presentations this is for all um acute care for any cause um I think impressive too is the fact that all of these patients were um open and very engaged with care um these were patients many of whom who had never um been able to show up for a Clinic appointment but I I think this just speaks volumes to the the care that Kate and Jamie provide and how they were able to build trusting relationships with with all of these patients um uh based on this pilot data um they're recently approved to continue this program going forward for at least the next two years and they've moved full-time to five days a week and their program has grown to now serve 64 patients which is super exciting um so coming back to our patient from the beginning of this talk um he was referred to the community heart failure program um given his struggles with medication compliance Kate and Jamie had this like ingenious idea to use an alarmed pill box um it is bought on Amazon it's only $55 and it basically you fill medicines for the whole month and it gets locked and every day it rotates to the to the new day and it'll sound both an audible alarm and Flash and LED light when it is time to take the medicines and it'll continue to alarm until the medicines are taken out out um for about two I think I think two hours otherwise it rotates to the next day and so when you come back it's also really easy to kind of assess medication compliance as well or sorry adherence as well um and you can see that he was still on very modest doses of gdmt um but he through this intervention was able to start taking them very consistently and his compliance went to 100% um he reported that he was still using meth and heroin but less and after just three months of this gdmt regimen you can see that his echo which are the three images on the bottom while not completely normal are dramatically better than they were when he was diagnosed um clinically he was able to come off of Loop Diuretics he has NY class one symptoms and reports that he's able to walk to the store that's a mile away and back without any limitation and he's remained out of the hospital since this echo cardiogram performed over six months ago um so if you're as impressed with these data as I am and want to get your patients referred to the community heart failure program um you would place a referral in Epic just like you would for another any other Cardiology referral select Harbor View and then in the drop-down menu um click on community heart failure program and please fill out the smart phrase um particularly important is to fill out the patients contact information so we can reach them um and then just to give a shout out to both Kate and Jamie who recently won uh the nursing clinical inquiry Award of the year um for all of the um incredible work that they've done with the heart filler uh program and they're also invited to speak at aha this year um and so you'll probably see them there and hear more about the great things that they're doing um moving on to the second thing um going on at Harborview there's a pilot program um of a Cardiology and addiction medicine clinic there this is born out of a Qi project that showed that of the 20 13 patients that were seen at Harbor viw Cardiology clinic in 2022 with methamphetamine Associated cardiopathy there were only nine referrals that were placed to addiction medicine and zero patients um from those referrals connected with addiction medicine um I think that we can do better and so our goal is to increase engagement in addiction care and to help try and streamline the processes to get patients connected um as many of you know the Harborview Cardiology clinic has moved to the Ninth and Jefferson building and in that space one day a week there is now an addiction medicine fellow and attending that are embedded there um and they're helping um uh manage the the substance use piece for a lot of our patients this pilot started in February and is um expected to go at least until June so far they've seen 20 patients um but have had many more visits than that including the the followup of those patients they're mostly seeing alcohol and methamphetamine use um but and then they're currently applying funding to continue this program and with Medicaid recently approving contingency management we hope that that's something that we would be able to implement as a part of um a future co-management Clinic similar to the one that I shared um that's happening in San Francisco um and then lastly um uh Cooper and I have put together what what I'm terming right now I guess the methampetamine research collaboration this is a group of actually 20 to 30 people who are all interested and passionate about um caring for patients um who use methamphetamine um it's a very multi-disciplinary Group which I think is really exciting um it includes Cardiology addiction medicine Psychiatry pulmonology and Internal Medicine um and it includes traines from the entire pipeline in addition to um uh attendings nurse practitioners nurses and Pharmacists and so it's a really um exciting group where we can come together and talk about ways that we can advance patient care all through sort of an academic lens um so to summarize um reaching the end of my talk um the take-home points that I hope you remember are that methamphetamine causes a toxin induced cardiomyopathy um uh features that favor reversibility include a patient's ability to stop using methamphetamine less fibrosis extent less chamber Remodeling on Echo um I think all of us can um strive to provide empathetic and trauma-informed care for all patients want to emphasize that contingency management works um that we should be getting all of our patients on optimal guideline directed medical therapy and please refer your patients test at Harborview thanks Danny that was incredible um I learned so much and I have to to say that I I I don't know about the rest of the audience but I definitely walk away feeling more hopeful um and uh and this is actually the data from the community heart failure program was very nice to see because as a as a physician who attends at Harborview certainly for the past year or so I feel like I'm seeing less of the same patients and so this just validates um everything that I'm seeing so it's very incredible um and thank you for for sort of uh continuing the work um that that you guys are going to be doing I I foresee great things coming forward with with you at the home there um I did have uh one question that sort of gets back to something you addressed very early on which was the gender differences in math indued cardiomyopathy and um and I had seen that also anecdotally um and I wasn't sure if it's because of of the differences in use or is it um more that men tend to males tend to develop more of the cardiomyopathy aspect and and or women develop more of the pulmonary Hy I'm not sure if there is a if um if there's a pathophysiologic difference or is this a difference in use do you have a sense of that at all I don't and I tried to look into that too because it is really notable there's a paper from 2018 that really showed nicely that you're right women are more likely to develop the phah phenotype from meth whereas men are more likely to to develop cardiomyopathy and they saw this in Mouse models as well I don't I don't know if it's a pattern of use or um some other Factor but I I suspect it's something biological um uh but I don't think we fully understand why why that gender differences exist yeah um I I have more questions but I kind of wanted to show it throw it out to the audience a little bit one of my short you need to do the um I think one of my shortcomings in in treating this population is is trying to kind of meet them where they're at and and maybe that's just my pessimism and saying I don't think this person can do gdmt they need to prove to me that they need to follow up before I can put an ICD in them um I don't think that they're going to be able to handle so many referrals so I don't refer them to addiction medicine um anecdotally I mean I know those are kind of three different things that you can take different approaches to but but what's been your experience in in in meeting these patients with optimism and trying to push them a little bit harder or or getting them on on B meds and please feel free to call on Kate and Jamie too to answer yeah definitely I mean I think that's a really um common sentiment that I think a lot of providers who want to help like often feel stuck and sometimes frustrated that um um the tools that we currently have are inadequate in serving this population that's one of the reasons why I think the work that what Kate and Jamie are doing is so incredible because I think that for many patients they are not um at the point in their lives where they're able to come to Clinic appointments and when you don't have your basic life needs met I think that sometimes can be a very tall ask and so I think Kate and Jamie are sort of changing the way that we deliver Healthcare in a way that um is more equitable and brings health care to the patient in a way um that they've all been very receptive to and so I think it's kind of turning what is normal and um you know going to Clinic like seeing 20 patients writing your notes you know I think I think it's about changing that perspective and really centering it around the patient um and I think we've already seen evidence that that's that that's working for patients who have sort of not um not thrived in the current the current way that we do Healthcare I don't know if you have Jamie might have something to say too no I thank you I totally agree I think there's a meeting patients where they are seems to have such a huge impact on outcomes and I also think that um this kind of gets into what you're talking about with like what we prescrib them at discharge kind of recognizing that we can make improvements both in functional abilities and even in things like EF um if we can get people to take medicines consistently even if they are not on optimized gdmt um and we can also by seeing them in the community and meeting them where they are and not making their health care contingent on quitting Medic or quitting methampetamine or other stimulants um they're more likely to engage and then continue to show up for care with Cardiology but also with other services and that um there can be Improvement and recovery even with continued use Danny thank you that was great um I was wondering if there's any research and I know this would be somewhat controversial but just thinking analogous to the way methadone and Suboxone have become main states of opiate addiction uh cessation is there any research in using long acting amphetamines um as uh Bridges to abstinence because they seem to be quite a bit safer than methamphetamine in terms of cardiotoxicity I mean of course they promote hypertension but they don't seem to promote elv thrombus and dilation and systolic dysfunction as much yeah no that's an excellent question um what I learned from the addiction medicine folks is that people have definitely looked into that in the same way that for opiate use disorder um you would think that it would work but unfortunately it does not pan out that way I think sometimes they still use Aderall and you know some prescribed stimulants um if they if they um you know ask patients the why why do you use what drives you to use a lot of people are self-medicating ADHD and so I think if the underlying diagnosis is they actually really do have ADHD and that's why they're using stimulants I think I think using um something like Aderall could be effective and helpful in that in those specific patients um but I don't think widely across the board as a treatment for stimulate use disorder it has been shown to to reduce use or be effective yeah really really nice talk Danny um very informative um I'm very interested in the piece about mechanism that you touched on a little bit earlier in your presentation and in particular like the opportunities maybe to think about this genetic second hit hypothesis um but you know the key to understanding mechanism is really having a lock on on the exposure and I'm curious if anyone has done any work actually sampling and looking at what these patients are taking we know that methamphetamine is produced in a range of places um where we don't know that much about what chemicals are going into it um have others run mass spec on what people are taking or have you thought it all about how to better understand what the exposure actually is that these folks are getting um that's a really good question I am blinking on the name of the website but there is for King County um a website in which they have sort of t tested everything that is quote unquote fentanyl everything that's quote unquote methamphetamine and they've done I think mask back on it to see kind of the contamination of other substances within within that and so they'll report that you know like x per of what is considered methamphetamine is actually feny or is actually contaminated with these other substances so I have seen data on that um I haven't I haven't seen a lot of data though on like the potency of of the drugs that are coming out I mean there was some longitudinal data from like the early 2000s to the late 2010s there was some graphs that I found that like the potency of the meth that is available in the US has dramatically increased to like almost 100% potency um when the shift of a lot of the production started coming from Mexico um but I haven't seen any like recent data um kind of more granularly defining the exposure so that would be that would be something either I'm not aware of or something that we could look into hey Dan thank you for this important talk now I'm particularly interested in the con and the contingency management and now that it's been approved by Washington State Medicaid what are the next steps to Rolling Out contingency management at Harborview and how do you in um how what are some ways that we could in uh you might be able to incorporate contingency Management in the registry yeah I think so I'm very excited um I think everything comes down to funding and um if we can get funding for it I think we have a lot of people who are very excited to try and you know roll out a co-management um Cardiology addiction medicine clinic um I think that um I think that right now the pilot program that is currently going on um they are not currently doing contingency management but kind of need approval from the higher ups in the hospital to be able to give basically something of monetary value to patients and so I think that there's a number of um logistical barriers that I think will need to kind of be be overcome but I think that's not impossible um especially because it's been so effective Kate may have more updated information about this awesome thank you Danny you're just awesome that was great um just just this week we met with the AAG of Washington state um to try to do contingency management at udub so if there are people who are interested and want to be present the more from them that we had Physicians showing up and Leadership and people really you know from Tim dallet down to me um showing that they were interested and wanted to work on this the better so just let me know where sarahy she's kind of spearheading it but yeah we're talking to Washington State so that's exciting that's super exciting wow great yeah any other questions in the audience great um I think that uh one um there was a question in the chat about ADD ADHD but I think you actually ended up answering that question and then uh one comment that Nona made which was uh very uh Illuminating was um about the gender differences she reminded that alcohol use disorder is also higher in men and and that can serve as a second hit so uh thanks Nona for the comment um thank you Danny this was incred at a ball and um I'm so excited to see kind of where you go with this um and sort of take all the leadership that you've already shown in fellowship and just sort of spearheading this program with Cooper and and um Kon um uh Kon and the team there so thank you Jamie yeah K and Jamie thank you all right thank you everyone