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🧠 Clinical Context:

For patients who absolutely cannot tolerate statins — despite trying multiple options or experiencing severe side effects.

Reminder: Always try multiple statins first (different types, dosages, timing) before declaring “statin intolerance.”

💊 What is Bempedoic Acid?

Non-statin oral agent, works upstream of HMG-CoA reductase.

Liver-activated – avoids muscle toxicity seen in statins.

First oral non-statin to reduce MACE-4 endpoints.

📈 Clinical Impact:

LDL-C reduction: 20–25%.

Cardiovascular events:

23% ↓ in MI.

19% ↓ in coronary revascularization.

⚠️ Adverse Effects:

Gout, gallstones, elevated transaminases.

Avoid if history of uric acid disorders.

🧩 Clinical Takeaway:

Great adjunct to maximally tolerated statin or for rare, true statin-intolerant patients.

Not first-line — statins remain king, with 40–50% LDL reduction.

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🧠 Clinical Context:

BBs have been MI standard since the thrombolysis era.

But do they still help when patients get PCI, statins, and ACEs?

🧪 Two Major Studies:

Swedish Registry Study:

Post-MI patients with preserved EF.

All received PCI + standard meds.

BB vs no BB: No difference in death or recurrent MI.

French Study (New England Journal):

MI 2.9 years prior, preserved EF.

BB continuation vs discontinuation:

Slight reduction in composite endpoint (death/MI/stroke/hospitalization).

Driven mostly by fewer hospitalizations (17% vs 19%).

⚖️ Pros and Cons of Beta Blockers:

✅ Pro: Cardioprotection, arrhythmia prevention.

❌ Con: Depression, fatigue, ED, bradycardia.

BBs aren’t benign — side effects matter to patients.

🧩 Clinical Pearls:

If EF is normal and patient is stable post-MI: Reassess need for long-term BB.

Ongoing trials will help guide “de-prescription” thresholds.

Don't forget individualized care: patient preference, arrhythmia risk, BP goals.

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🧠 Clinical Context:

Episodic migraines (<15 days/month) that don’t respond to traditional preventives.

Patients often fail beta blockers, AEDs, TCAs, CCBs — need new options.

🧪 Study – RCT on Atogepant:

315 patients, mostly women, who failed ≥2 oral preventives.

Randomized to atogepant 60 mg daily vs placebo.

Follow-up: 3 months.

📈 Outcomes:

≥50% migraine reduction:

51% in atogepant group vs 18% placebo.

Most common side effect: Constipation (10% vs 3%).

💊 Mechanism:

CGRP receptor antagonist – blocks calcitonin gene-related peptide, a known migraine mediator.

🧩 Clinical Application:

Strong option for treatment-refractory episodic migraine.

Easier than injectables; potential for earlier use in future guidelines.

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🧠 Clinical Context:

Blood pressure errors due to bad positioning = misdiagnosis and mistreatment.

We often blame the drug, when the data was flawed to begin with.

🧪 Study Highlights:

104 patients tested with 3 positions:

Hand in lap: BP falsely elevated by 4 mmHg.

Arm unsupported: +6 mmHg (most common real-world scenario).

Arm supported at heart level: accurate.

✅ Gold Standard Technique:

Seated, feet flat on floor, arm supported at heart level, relaxed.

No caffeine, nicotine, or exercise 30 minutes prior.

No talking. Cuff on bare skin, correct size (80% of upper arm).

Wait 5 minutes pre-reading. Repeat if >5 mmHg difference.

⚠️ Clinical Consequences:

Misclassified HTN → overtreatment, hypotension, dizziness.

Standardize BP checks in your clinic—“militant consistency” matters.

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🧠 Clinical Context:

Nursing home residents are fragile fall-prone patients.

Starting a new antihypertensive could trigger orthostasis → serious fractures.

🧪 Study – VA Nursing Home Cohort:

13,000+ residents tracked from 2006–2019, mean age ~78.

Examined fracture risk 30 days after starting an antihypertensive.

Fractures studied: Pelvic, hip (requiring surgery), humerus, radius, ulna.

📈 Outcomes:

New antihypertensive initiated → 4.5 serious falls per 100 person-years.

No med change → 2.2 events per 100 person-years.

That’s >2x risk with a new med.

🩺 Clinical Tips:

Orthostatic BP check should be done 3–6 minutes after standing (not just 1–2 min).

Median best time: 4.5 minutes.

Use shared decision-making: Is the BP goal worth a possible hip fracture?

Consider deprescribing or "start low, go slow" approach in long-term care.

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🧠 Clinical Context:

Subclinical atrial fibrillation = asymptomatic episodes of AF detected by implantable monitors or Holters, lasting 6 minutes to 24 hours.

Big Question: Should we anticoagulate these patients?

🧪 Study Highlights – ARTESiA Trial:

Design: 4,012 patients (mean age 76.8), randomized to apixaban 5 mg BID vs ASA 81 mg daily.

Inclusion: Age >55 with or without history of stroke/TIA; device-confirmed subclinical AF.

📈 Outcomes:

Primary endpoint: Stroke or systemic embolism.

With prior stroke/TIA:

Apixaban significantly reduced events: 1.2% vs 3.4% annually.

Without prior stroke/TIA:

No significant difference: 0.74% (apixaban) vs 1.07% (ASA).

🧩 Clinical Pearls:

Don’t reflexively anticoagulate all device-detected AF — stratify by stroke history.

Consider CHA₂DS₂-VASc, but more importantly, patient-specific functional risk.

Use the Modified Rankin Scale to contextualize why stroke prevention matters:

0 = no symptoms, 5 = severe disability, 6 = death.

Patient framing tip: “If a stroke leaves you unable to walk, speak, or go to the bathroom independently, would that be worth preventing with a pill?”

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🧪 VOYAGER-PAD Trial:

Patients with PAD post lower extremity revascularization.

Rivaroxaban 2.5 mg BID + aspirin vs aspirin alone.

📈 Results:

↓ Major Adverse CV Events (MACE).

↓ Major Adverse Limb Events (MALE).

Modest ↑ in bleeding — no ↑ in fatal bleeds.

🧩 Clinical Takeaway:

Now guideline-endorsed for symptomatic PAD post-intervention.

Risk-benefit conversation needed in high-bleed-risk patients.

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🧪 Key Insights:

Observational data links semaglutide (GLP-1 RA) to increased risk of non-arteritic anterior ischemic optic neuropathy (NAION).

Incidence: ~9–15 cases per 100,000 patient-years.

Possible mechanism: GLP-1 receptors in optic nerve ganglion cells.

No proven causality yet — retrospective study only.

🧩 Clinical Takeaway:

Risk remains very low.

Discuss with patients who have eye disease or prior NAION before initiating therapy.

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🧪 Key Findings:

Cohort study: SGLT2 inhibitors led to significantly lower rates of nephrolithiasis compared to GLP-1 RAs.

Mechanism: increased urinary flow and uric acid excretion.

🔢 Stats:

NNT = 20 for prevention.

NNT = 5 for recurrent stone formers.

🧩 Clinical Takeaway:

Another bonus benefit of SGLT2 inhibitors.

May sway decision in diabetics prone to stones.

HCTZ no longer holds the same weight in stone prevention.

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🧠 Problem:

RLS causes chronic sleep disruption, often worsens in hospital or peri-op settings.

💊 Management:

First-line: Gabapentin or Pregabalin (per American Academy of Sleep Medicine).

Avoid long-term dopamine agonists — cause augmentation and impulse control disorders.

🩸 Bonus Tip:

Check ferritin — keep it >75 ng/mL.

Oral or IV iron can help symptom control.

🧩 Clinical Takeaway:

Treat aggressively; it’s more than “just annoying.”

Avoid benzos and older agents unless no better option.

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