Heart Failure with Preserved Ejection Fraction - Managing Comorbidities

Heart failure (HF) is a complex condition characterized by signs of volume overload or symptoms such as dyspnea, exercise intolerance, and fatigue. Being a syndrome, HF is not explained by one unifying pathophysiologic cause.  Rather, various mechanisms lead to the deficit between the amount of blood delivered and the amount of blood that needs to be delivered through the body to maintain homeostasis.  HF is defined as the previously mentioned signs or symptoms being caused by structural or functional cardiac abnormalities plus either 1) elevated natriuretic peptides (e.g., BNP) or 2) objective evidence of

Goodbye to Andexanet Alfa (AndexxaⓇ)

Andexanet alfa (Andexxa) made its quiet exit from the U.S. market just a few weeks ago.  It's an interesting story so in case you missed it, I'll recap what andexanet alfa is, or rather was, and what happened that led to its removal.  Being pulled from the U.S. market may have come to a surprise for some considering its main study (ANNEXA-I) was stopped early for successfully meeting its main efficacy outcome. While having a trial stopped early for superior efficacy results sounds good on the surface, it can have negative ramifications on other aspects of the clinical inquiry (explained below).

Treating Insomnia in Older Adults: Doxepin Highlights

The American Geriatrics Society recently published their Alternative Treatments to Selected Medications in reference to the most recent update to the AGS Beers Criteria in 2023.  This guidance is helpful because while the 2023 AGS Beers Criteria warned about which medications were "potentially inappropriate" in older adults, they left clinicians guessing by not offering suggestions as to which medications should alternatively be used.

Dyspnea Associated with Ticagrelor

Ticagrelor is an antiplatelet medication that is commonly used for a number of cardiovascular conditions.  Its mechanism is similar to that of antiplatelet medications clopidogrel and prasugrel in that it inhibits P2Y12 ADP receptors on platelets, preventing platelet activation and aggregation.  Ticagrelor is different from clopidogrel and prasugrel in that it binds reversibly to the receptor and, importantly, it is administered as the active compound.  This contrasts with clopidogrel and prasugrel which require metabolic activation by CYP450 enzymes and are therefore susceptible to drug interactions and altered activation in those with polymorphic CYP450 phenotypes (clopidogrel requires two CYP450 enzyme steps for

Thiamine deficiency and supplementation in heart failure

Thiamine is a water-soluble vitamin that is an important coenzyme for various metabolic processes in the body.  These include the regulation of glucose metabolism, the Krebs cycle (generates ATP), the pentose shunt (generates NADPH), and maintenance of sodium/potassium gradients in the brain (necessary for conducting nerve impulses).  Thiamine is mostly obtained from dietary intake with absorption occurring in the jejunum and ileum. After traveling to the liver, thiamine spends a relatively short amount of time in the blood before distributing to tissues throughout

Beers Criteria Update 2023 - Seven Changes

The American Geriatrics Society (AGS) 2023 updated AGS Beers Criteria® for potentially inappropriate medication (PIM) use in older adults was released during the AGS annual meeting in May 2023.  This is the sixth update to the criteria which are currently designed to identify potentially inappropriate medications (PIMs) that are best avoided in older adults in general or in specific circumstances.  The criteria were first intended to be applied to the nursing home population but were expanded to apply to all adults 65 years old and older (except for end-of-life settings).