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my task is to visit with you about the guidelines my disclosures are here I have no relationships with industry I am going to go through the information that would have set context and begin here beginning to iterations of the guidelines ago in 2003 under the direction of dr. hunt that guideline was published in 2005 then later again for the 2009 iteration of the guideline that was under the direction of dr. Jessop we began incorporating this notion of the stages of heart failure one reminds you that this progresses from your left to your right there are two stages stage a and B that are pre heart failure and then there are stages C and D which represents symptomatic heart failure that is having ever had symptoms or having refractory symptoms this is by way of review for most of you but its also by way of emphasis remember this guideline paradigm didnt begin until 1995 and weve since refined and increased our embrace of the guideline and develop this framework over the last couple