Brilliant Board Review & CME

Send a text 🧠 Clinical Context: You're prepping a patient for non-cardiac surgery —what's their cardiovascular risk? Turns out, it’s not always about echo reports or cath results. It starts with a stairs test (sort of). Duke Activity Status Index (DASI) and METs >4 can tell you if the heart's got enough reserve. 🚶‍♂️ “Can you walk up a flight of stairs without gasping?” If yes,...

Send a text 🧠 Clinical Context DOACs (Direct Oral Anticoagulants) have revolutionized anticoagulation—goodbye routine INRs, hello convenience. But while they’ve made our lives easier, they’re not always a fit for every scenario. Here's how to navigate the DOAC jungle. ✅ When DOACs Are Preferred Venous Thromboembolism (VTE) Atrial Fibrillation ⚠️ Exclude patients with: Mechanical heart valve...

Send a text 🧠 Clinical Context GLP-1 receptor agonists have taken center stage for both type 2 diabetes and obesity management , but their gastric side effects are giving anesthesiologists pause. The ASA's recent guidance recommends holding these agents before surgery to reduce risks of gastroparesis , regurgitation , and pulmonary aspiration . 🔬 ASA Guidelines Overview Daily Dosing? Hold o...

Send a text 🧠 Clinical Context Hydrochlorothiazide (HCTZ) vs. Chlorthalidone—a classic cardio debate! ALHAT once hinted at chlorthalidone’s superiority, but did a modern head-to-head trial confirm that? Let's break it down. 🧪 Study Snapshot: The HEADS-UP Trial Design: Randomized, head-to-head trial Population: ~14,000 patients, age ≥65, already on HCTZ 25–50 mg + 1–2 antihypertensives Prior...

Send a text 🧠 Clinical Context Patients over 65 undergoing inpatient surgery face unique risks. Cognitive impairment, frailty, and increased vulnerability to delirium demand a proactive and nuanced approach to anesthesia and postoperative care. 🔍 Preoperative Priorities Age ≥65 and inpatient status should automatically trigger a frailty and cognitive assessment Engage a multidisciplinary team ea...

Send a text 🧠 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 his...

Send a text 🧠 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, uln...

Send a text 🧠 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 Standar...

Send a text 🧠 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 a...

Send a text 🧠 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 co...

Send a text 🧠 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 toxic...

Send a text 🧠 Clinical Question: What's the optimal hemoglobin threshold for transfusion post-MI? Old dogma: “Keep Hgb >10” . New data: Less might be just as safe . 🧪 The MINT Trial (Myocardial Ischemia & Transfusion): Compared liberal (Hgb <10) vs restrictive (Hgb <8) transfusion strategies. Lower 30-day recurrent MI or cardiac death seen with Hgb ≥10 approach. But... secondar...

Send a text 🧠 Clinical Problem: Behavioral disturbances in Alzheimer’s are notoriously hard to treat. Guidelines tell us: “Don’t use antipsychotics” — but what do you do at 2AM when Nana's throwing punches? 💊 Study Overview: 345 patients , moderate-severe Alzheimer’s + aggressive agitation. Brexpiprazole 2–3 mg daily vs placebo. Dosing didn’t differ much in effect. 📈 Outcomes: Significant...

Send a text 🧠 Clinical Context: Hypertrophic obstructive cardiomyopathy (HOCM) : Genetic disorder causing LVOT obstruction . Traditionally managed with BBs, CCBs, disopyramide… or surgery. 💊 Drug: Mavacamten (Cardiac Myosin Inhibitor) Targets sarcomeric hypercontractility directly. FDA approved for NYHA Class II–III obstructive HCM. 🧪 EXPLORER-HCM Trial: 62-week follow-up : ↓ LVOT gradient (res...

Send a text 🧠 Clinical Background: Inflammation plays a big role in atherothrombosis . Colchicine — an old gout drug — shows promise in CV risk reduction . 🧪 COLCOT Trial: Colchicine 0.5 mg daily post-MI. Greatest benefit in patients with type 2 diabetes . 📈 Outcomes: Reduced MACE (MI, stroke, death) in diabetics. Adverse Effects : Nausea, diarrhea, ↑ risk of pneumonia (unclear why). 🧩 Clinica...

Send a text 🧠 Clinical Context: Historically, breast cancer treatment has included radical mastectomies and full axillary dissections . New data supports less invasive approaches for specific low-risk populations . 🧪 The SOUND Trial (and similar studies): T1–T2 tumors (≤5 cm), clinically node-negative , ER+ . Compared no axillary surgery vs sentinel lymph node biopsy . No difference in outcomes...

Send a text 🧠 Clinical Question: Are we overtreating bloodstream infections with 14-day regimens ? 🧪 Study Overview: Multicenter RCT in ICU/inpatient settings (7 vs 14 days of antibiotics). Excluded : Immunosuppressed, endocarditis, Staph aureus, and infections needing longer therapy. 📈 Findings: No difference in 90-day mortality or relapse. More C. diff and drug reactions in the 14-day group....

Send a text 🧠 Clinical Myth: “Delay levodopa to delay motor complications.” 🧪 LEAP Trial (Levodopa in Early Parkinson’s): Compared early start vs 40-week delayed start . 5-year follow-up showed no difference in motor fluctuations or dyskinesia . 📈 Key Outcomes: Early levodopa = better function earlier , no long-term harm . Wearing off effect was similar in both groups. 🧩 Clinical Takeaway: Don...

Send a text 🧠 Clinical Context Fever is known to be associated with worse neurologic outcomes in stroke, both ischemic and hemorrhagic. Intuitively, preventing fever seems like a slam-dunk goal, right? This study took that theory to trial, literally. 🧪 Study Highlights: The INTREPID Trial Design: Open-label, randomized controlled trial with blinded outcome assessment Setting: 43 ICUs across 7 co...

Send a text 🧠 Clinical Problem: HFpEF (Heart Failure with Preserved EF) has lacked effective, proven therapies. Finerenone (non-steroidal MRA) offers new hope. 🧪 FINEARTS-HF Trial: 6,000+ patients with EF ≥40% , followed for ~32 months. Compared Finerenone vs placebo . 📈 Results: ↓ Heart failure hospitalization significantly. No significant reduction in CV mortality . Hyperkalemia : 9.7% (Finer...

Send a text 🧠 Hidden epidemic: 50–70% of premenopausal women have iron deficiency. Also common in CKD, GI bleeding, chronic disease . 🔍 Diagnosis Pearls: Ferritin cutoff: <30 ng/mL (not 20!) for iron deficiency. RLS patients: target ferritin >75 . Consider retic count: low = underproduction; high = bleeding/hemolysis. 💊 Treatment Tips: Oral iron : ferrous sulfate preferred; daily dosing &...

Send a text 🧠 Clinical Context Heart failure with preserved ejection fraction (HFpEF) typically presents with orthopnea, dyspnea, edema, and often subtle signs like an S3 or elevated JVP—despite a normal EF (>50%). Diagnosing it requires nuance, and ruling out other causes of dyspnea is key. 🧪 Rule Out First Before calling it HFpEF, think differentials: Anemia Cirrhosis COPD exacerbation Rena...

Send a text 🧠 Clinical Problem: HFpEF (Heart Failure with Preserved EF) has lacked effective, proven therapies. Finerenone (non-steroidal MRA) offers new hope. 🧪 FINEARTS-HF Trial: 6,000+ patients with EF ≥40% , followed for ~32 months. Compared Finerenone vs placebo . 📈 Results: ↓ Heart failure hospitalization significantly. No significant reduction in CV mortality . Hyperkalemia : 9.7% (Finer...

Send a text 🧠 Clinical Context We’ve long been taught to stop metformin once GFR drops below 30 due to concerns about lactic acidosis. But what if—just maybe—some patients might actually do better by continuing it? Enter a large-scale Scottish national database review that turned this dogma on its head. 🧪 Study Highlights Design: Retrospective analysis of a national database in Scotland Populati...

Send a text 🧠 Background: RSV causes significant morbidity/mortality in older adults . Previously considered a pediatric virus only. 📈 Epidemiology: Hospitalization rate: 91/100,000 (ages 64–74). 738/100,000 in assisted living patients. 💉 Vaccine Update: CDC now recommends RSV vaccine for: All ≥75 years old . 60–74 years with chronic conditions (lung, kidney, diabetes with organ damage). Effica...