WEBVTT 00:00:00.299 --> 00:00:03.883 A pregnancy complication can disappear from the chart long before it stops 00:00:03.968 --> 00:00:07.552 being relevant to prevention. What changes when we ask about it? 00:00:07.765 --> 00:00:10.003 Welcome to HEART RESERVE Clinical Conversations. 00:00:10.278 --> 00:00:14.097 I’m Lisa Zahakos, a physician assistant and founder of HEART RESERVE. 00:00:14.374 --> 00:00:18.256 In this episode, we’ll follow Nina after delivery, Maria at a preventive 00:00:18.384 --> 00:00:20.603 visit, and Elena after a heart attack. 00:00:20.902 --> 00:00:23.151 These are fictional teaching cases for clinicians. 00:00:23.480 --> 00:00:26.637 You can listen straight through, or use the chapters to return to 00:00:26.680 --> 00:00:29.709 a case. I’ll ask you to consider a few decisions and then 00:00:29.794 --> 00:00:33.933 walk through the reasoning. The activity page has the objectives, references and 00:00:33.976 --> 00:00:36.557 online questions. Let’s start with Nina. 00:00:36.834 --> 00:00:39.032 A postpartum handoff that needs an owner. 00:00:39.309 --> 00:00:41.805 Nina is 34 and eight weeks postpartum. 00:00:42.040 --> 00:00:45.832 Her pregnancy was complicated by preeclampsia and gestational diabetes. 00:00:46.041 --> 00:00:48.771 She delivered at 34 weeks and is spending much of her time 00:00:48.857 --> 00:00:50.777 at the neonatal intensive care unit. 00:00:51.033 --> 00:00:55.214 An early blood-pressure check occurred, but the obstetric and primary care records 00:00:55.299 --> 00:00:57.974 do not show who owns her long-term follow-up. 00:00:58.259 --> 00:01:02.697 She is breastfeeding, has no acute symptoms, and has not completed postpartum 00:01:02.739 --> 00:01:05.897 glucose testing. Ask before adding another task. 00:01:06.281 --> 00:01:10.132 Nina says, “I thought the blood pressure problem ended when I delivered.” 00:01:10.308 --> 00:01:13.678 Ask what she was told, what testing has already happened, and what 00:01:13.721 --> 00:01:18.500 makes the next appointment difficult. Obtain the discharge summary, recorded blood pressures, 00:01:18.713 --> 00:01:22.433 pregnancy diagnoses, medicines and available laboratory results. 00:01:22.782 --> 00:01:26.921 Record the year and gestational age of the affected pregnancy and distinguish 00:01:27.006 --> 00:01:29.776 a confirmed diagnosis from the patient’s recollection. 00:01:30.113 --> 00:01:33.100 A history of an adverse pregnancy outcome is a reason to assess 00:01:33.185 --> 00:01:35.745 present risk and maintain preventive care. 00:01:36.086 --> 00:01:38.639 It does not establish that Nina has coronary disease. 00:01:38.930 --> 00:01:46.013 Blood pressure, glycemia, lipid assessment, kidney status when indicated, tobacco exposure, physical 00:01:46.226 --> 00:01:50.271 activity, food access and sleep each contribute information. 00:01:50.646 --> 00:01:56.577 The 2026 American College of Cardiology postpartum pathway emphasizes coordinated follow-up for 00:01:56.619 --> 00:01:59.755 patients with or at risk for cardiovascular complications. 00:02:00.075 --> 00:02:04.464 Here is the decision. Which plan best addresses the immediate care gap? 00:02:04.912 --> 00:02:07.233 Pause here if you would like a moment to think it through. 00:02:07.506 --> 00:02:10.962 The best next step in this case is: Arrange the postpartum glucose 00:02:11.047 --> 00:02:14.503 test, a feasible appointment and a named clinician to review and act 00:02:14.589 --> 00:02:18.301 on the result. The recommended plan completes both the clinical task and 00:02:18.343 --> 00:02:22.993 the handoff. The alternative leaves the scheduling and responsibility gaps unresolved. 00:02:23.228 --> 00:02:26.599 The alternative delays an indicated postpartum glucose assessment. 00:02:26.812 --> 00:02:30.086 Ask what makes the visit difficult before finalizing the appointment. 00:02:30.330 --> 00:02:32.890 Separate the urgent problem from the prevention visit. 00:02:33.146 --> 00:02:36.388 Start with symptoms and the current blood pressure, not the list of 00:02:36.431 --> 00:02:40.961 incomplete screening tasks. Nina has no acute symptoms in the opening vignette. 00:02:41.182 --> 00:02:44.596 A later telephone call is a new clinical situation and requires a 00:02:44.638 --> 00:02:48.265 new urgency decision. Do not carry the reassurance from the first visit 00:02:48.478 --> 00:02:52.722 into the second encounter. A useful history asks what happened, when it 00:02:52.765 --> 00:02:55.892 happened, how severe it was, and what remains unresolved. 00:02:56.075 --> 00:03:02.232 “Preeclampsia; delivery at 34 weeks; discharge summary requested” gives another clinician more 00:03:02.275 --> 00:03:08.111 information than “pregnancy problem.” Record patient-reported information as such while obtaining records. 00:03:08.443 --> 00:03:11.579 Avoid making the patient repeat her story to every service. 00:03:11.984 --> 00:03:17.008 Time the right test. American Diabetes Association recommends a fasting 75 gram 00:03:17.136 --> 00:03:21.680 oral glucose tolerance test at 4 to 12 weeks after gestational diabetes, 00:03:21.872 --> 00:03:26.631 interpreted with nonpregnancy criteria. In this early period, an A one C 00:03:26.802 --> 00:03:29.891 does not replace the recommended oral glucose tolerance test. 00:03:30.207 --> 00:03:34.559 Even a normal result does not end follow-up: ongoing screening for prediabetes 00:03:34.730 --> 00:03:38.228 or type 2 diabetes is recommended every 1 to 3 years. 00:03:38.527 --> 00:03:39.743 Put the plan into the record. 00:03:39.935 --> 00:03:42.055 The practice can arrange testing next week. 00:03:42.341 --> 00:03:44.517 Nina prefers a phone call after 3 PM. 00:03:44.858 --> 00:03:48.869 The primary care physician assistant accepts responsibility for reviewing the result and 00:03:48.911 --> 00:03:52.654 contacting her. In this worked example, the team checks for a result 00:03:52.824 --> 00:03:56.024 within two working days of the planned test and calls if the 00:03:56.067 --> 00:04:00.675 test was missed. These operational deadlines are examples, not guideline intervals. 00:04:01.016 --> 00:04:04.705 Here is the decision. Before the test, Nina calls with new chest 00:04:04.790 --> 00:04:07.884 pain and difficulty breathing. What should the team do? 00:04:08.247 --> 00:04:10.542 Pause here if you would like a moment to think it through. 00:04:10.832 --> 00:04:14.458 The best next step in this case is: Arrange emergency assessment now 00:04:14.629 --> 00:04:17.424 and communicate her recent pregnancy and complications. 00:04:17.872 --> 00:04:21.703 New postpartum chest pain and breathing difficulty warrant emergency assessment. 00:04:21.951 --> 00:04:25.322 An office appointment or home measurements must not delay that evaluation. 00:04:25.621 --> 00:04:28.266 Do not diagnose anxiety from this telephone description. 00:04:28.607 --> 00:04:33.897 Teach the earlier postpartum window. American College of Obstetricians and Gynecologists recommends 00:04:34.026 --> 00:04:38.505 blood-pressure evaluation no later than 7 to 10 days postpartum after a 00:04:38.548 --> 00:04:43.959 hypertensive disorder of pregnancy. The 2026 American College of Cardiology pathway specifies 00:04:44.045 --> 00:04:49.591 evaluation within 72 hours after discharge for patients with severe hypertension during 00:04:49.720 --> 00:04:54.687 the delivery hospitalization. Current severe blood pressure or concerning symptoms require urgent 00:04:54.773 --> 00:04:57.098 assessment, not a wait for that appointment. 00:04:57.504 --> 00:05:00.213 Nina’s eight-week visit continues the earlier surveillance. 00:05:00.448 --> 00:05:02.047 A note another clinician can use. 00:05:02.238 --> 00:05:07.827 “Preeclampsia and gestational diabetes in 2026, delivery at 34 weeks. 00:05:08.104 --> 00:05:11.848 Current symptoms reviewed. Early blood pressure follow-up verified. 00:05:12.222 --> 00:05:15.738 Postpartum oral glucose tolerance test arranged for the agreed date. 00:05:16.054 --> 00:05:19.297 the named clinician or team will review the result and contact the 00:05:19.340 --> 00:05:22.881 patient by the agreed date; if missed, the designated team member will 00:05:22.924 --> 00:05:24.923 call using the agreed contact method. 00:05:25.258 --> 00:05:29.567 Cardiovascular and metabolic follow-up booked for the agreed date.” Add the actual 00:05:29.781 --> 00:05:34.602 blood pressure, medication reconciliation, renal findings when relevant and the patient’s next 00:05:34.688 --> 00:05:38.500 pregnancy plans. Confirm receipt of a referral rather than treating a sent 00:05:38.543 --> 00:05:41.871 referral as a completed visit. Make a missed step visible. 00:05:42.127 --> 00:05:45.894 An order, a completed test and an acted-on result are different events. 00:05:46.248 --> 00:05:49.384 In this illustrative workflow, the team records each separately. 00:05:49.618 --> 00:05:52.434 If the test is missed, ask what made it difficult and agree 00:05:52.477 --> 00:05:56.133 on a feasible next step. If the result is abnormal, the responsible 00:05:56.305 --> 00:06:00.485 clinician interprets it and arranges appropriate care; a reminder alone does not 00:06:00.529 --> 00:06:05.093 complete that task. Use teach-back to check your explanation: “I want to 00:06:05.136 --> 00:06:06.595 be sure I explained this clearly. 00:06:06.901 --> 00:06:09.929 What is the next step, and who will contact you?” Ask how 00:06:09.972 --> 00:06:11.359 the patient wants to be reached. 00:06:11.722 --> 00:06:14.324 Coordinate appointments around infant care when possible. 00:06:14.708 --> 00:06:19.130 These workflow choices are practice examples, not prescribed guideline intervals. 00:06:19.413 --> 00:06:23.850 Patient explanation. “What happened in pregnancy is useful information for your health 00:06:24.021 --> 00:06:26.880 now. It gives us a reason to keep checking blood pressure and 00:06:26.965 --> 00:06:29.450 blood sugar and to review other heart risks. 00:06:29.759 --> 00:06:32.916 We can make a plan that works around the neonatal intensive care 00:06:32.959 --> 00:06:36.927 unit. I will tell you who is checking each result.” The takeaway 00:06:36.970 --> 00:06:40.383 from this case: Start with current symptoms and urgency. 00:06:40.639 --> 00:06:45.993 Complete indicated postpartum testing. Name who reviews the result and who contacts 00:06:46.079 --> 00:06:49.816 the patient. Now let’s move forward to Maria’s preventive visit. 00:06:50.072 --> 00:06:52.760 A pregnancy history missing from midlife prevention. 00:06:53.031 --> 00:06:55.727 Maria is 46 and attends a preventive visit. 00:06:56.022 --> 00:07:00.405 She has no known atherosclerotic cardiovascular disease or diabetes and no current 00:07:00.531 --> 00:07:05.883 symptoms. L D L cholesterol is 158 milligrams per deciliter, H D 00:07:05.925 --> 00:07:12.319 L cholesterol 49 milligrams per deciliter and triglycerides 145 milligrams per deciliter. 00:07:12.601 --> 00:07:16.141 She reports treated hypertension and a father who had a myocardial infarction 00:07:16.309 --> 00:07:18.775 at 49. She does not smoke. 00:07:19.217 --> 00:07:23.178 When asked directly, she describes severe preeclampsia with a delivery at 31 00:07:23.221 --> 00:07:26.045 weeks. Her chart does not contain this history. 00:07:26.445 --> 00:07:30.357 She is not pregnant or breastfeeding and has no current pregnancy plans. 00:07:30.586 --> 00:07:34.340 Here is the decision. How should the clinician use the newly elicited 00:07:34.511 --> 00:07:37.519 pregnancy history? Pause here if you would like a moment to think 00:07:37.563 --> 00:07:41.189 it through. The best next step in this case is: Document the 00:07:41.232 --> 00:07:44.901 history, complete the current assessment and discuss the full set of risk 00:07:44.987 --> 00:07:49.640 information. Pregnancy history informs the assessment alongside current risk factors. 00:07:49.918 --> 00:07:55.627 The alternative omits relevant clinical context; The alternative invents an unvalidated adjustment. 00:07:55.874 --> 00:08:00.865 Obtain the missing inputs before using PREVENT atherosclerotic cardiovascular disease and do 00:08:00.909 --> 00:08:03.149 not assign a score from this abbreviated case. 00:08:03.341 --> 00:08:05.487 What is missing before the risk calculation. 00:08:05.840 --> 00:08:11.088 Maria belongs in a primary-prevention assessment because no atherosclerotic cardiovascular disease event 00:08:11.174 --> 00:08:15.167 is reported. The abbreviated vignette does not supply a complete current blood 00:08:15.210 --> 00:08:20.031 pressure, total cholesterol, body mass index or kidney assessment, and her medication 00:08:20.202 --> 00:08:24.789 record needs confirmation. Obtain the inputs required by the current validated calculator 00:08:24.917 --> 00:08:28.586 rather than substituting estimates. The PREVENT result is one part of a 00:08:28.629 --> 00:08:32.116 discussion that also considers reproductive risk markers and family history. 00:08:32.446 --> 00:08:37.865 Keep the tasks distinct: record the pregnancy history, measure current risks, interpret 00:08:37.908 --> 00:08:40.779 the calculated estimate, then discuss treatment. 00:08:41.047 --> 00:08:45.143 Do not add an arbitrary percentage for preeclampsia or substitute the lipoprotein 00:08:45.185 --> 00:08:46.849 a concentration for a risk score. 00:08:47.063 --> 00:08:50.348 A low short-term estimate is also not permission to erase an important 00:08:50.434 --> 00:08:53.635 history from the record. Use additional tests for a decision. 00:08:53.955 --> 00:08:58.733 The 2026 dyslipidemia guideline recommends lipoprotein a measurement at least once in 00:08:58.777 --> 00:09:02.198 adulthood and selective apolipoprotein B assessment. 00:09:02.504 --> 00:09:06.515 lipoprotein a can reveal inherited risk not evident from a standard lipid 00:09:06.558 --> 00:09:12.475 panel. apolipoprotein B may help when cholesterol concentrations and atherogenic particle burden 00:09:12.560 --> 00:09:17.415 are discordant, including selected patients with metabolic disease or high triglycerides. 00:09:17.747 --> 00:09:20.690 A test is useful when its result changes the risk discussion or 00:09:20.776 --> 00:09:25.619 management. Maria’s lipoprotein a returns at 165 nanomoles per liter. 00:09:25.854 --> 00:09:30.447 Record the laboratory units exactly. Avoid a fixed conversion between nanomoles per 00:09:30.490 --> 00:09:34.543 liter and milligrams per deciliter. Explain that the result supports closer attention 00:09:34.756 --> 00:09:38.511 to modifiable risks and family history; it is not a measurement of 00:09:38.554 --> 00:09:42.325 an arterial blockage. Do not promise that diet will normalize an inherited 00:09:42.453 --> 00:09:45.606 lipoprotein a level. Build a feasible prevention plan. 00:09:45.901 --> 00:09:51.362 Discuss blood-pressure control, a heart-healthy dietary pattern, activity appropriate to function, smoking 00:09:51.533 --> 00:09:53.816 avoidance and medication options when indicated. 00:09:54.050 --> 00:09:58.593 Ask what Maria can sustain. A registered dietitian can help translate dietary 00:09:58.765 --> 00:10:01.922 advice into meals, budget and cultural preferences. 00:10:02.135 --> 00:10:06.273 Document the next measurement and review date rather than ending with “lifestyle 00:10:06.359 --> 00:10:10.088 counseling provided.” Reproductive plans can change the prescription. 00:10:10.515 --> 00:10:14.995 Consider a separate 34-year-old patient with hyperlipidemia who takes a statin for 00:10:15.038 --> 00:10:17.694 primary prevention and now wants to become pregnant. 00:10:17.960 --> 00:10:20.349 Her case requires a different discussion from Maria’s. 00:10:20.520 --> 00:10:26.834 Confirm the medication, dose, indication, current pregnancy status, plans, contraceptive method and 00:10:26.877 --> 00:10:31.744 breastfeeding status. Avoid assuming that age alone establishes whether pregnancy is possible. 00:10:32.278 --> 00:10:35.541 Here is the decision. Which counseling statement is most appropriate? 00:10:35.776 --> 00:10:37.924 Pause here if you would like a moment to think it through. 00:10:38.195 --> 00:10:41.650 The best next step in this case is: “Let’s review the exact 00:10:41.821 --> 00:10:45.874 medicine and indication with your prescriber before conception and agree on continuing 00:10:46.003 --> 00:10:50.918 cardiovascular care.” Plan the treatment transition before conception with the prescriber. 00:10:51.216 --> 00:10:55.187 The alternative postpones the discussion; The alternative interrupts follow-up. 00:10:55.360 --> 00:11:00.394 Most pregnant patients discontinue statins, while very high-risk exceptions need individual specialist 00:11:00.522 --> 00:11:05.803 assessment. FDA advises against breastfeeding when ongoing statin treatment is required. 00:11:06.092 --> 00:11:08.354 Questions that prevent an incomplete transition. 00:11:08.652 --> 00:11:11.809 Why was this medicine prescribed, and how high is the patient’s current 00:11:11.938 --> 00:11:16.289 risk? What does the current product information say for conception, pregnancy and 00:11:16.290 --> 00:11:20.194 lactation? Who will agree on the timing, provide an alternative when needed 00:11:20.408 --> 00:11:23.864 and monitor the patient? How will the plan be revisited after delivery 00:11:24.162 --> 00:11:29.947 or when breastfeeding ends? The 2026 guideline generally defers most lipid-lowering therapies 00:11:30.075 --> 00:11:36.591 during conception, pregnancy and lactation. For established atherosclerotic cardiovascular disease or severe 00:11:36.677 --> 00:11:42.493 familial hypercholesterolemia, coordinate preventive cardiology or lipid expertise with obstetric care. 00:11:42.762 --> 00:11:46.943 Do not apply one washout rule to every drug, substitute an investigational 00:11:47.156 --> 00:11:50.024 therapy, or leave a high-risk patient without follow-up. 00:11:50.203 --> 00:11:53.839 “Before you start trying to conceive, let’s review the medication with the 00:11:53.882 --> 00:11:57.039 clinician who prescribed it. We will agree on when to change it 00:11:57.124 --> 00:12:00.111 and how to look after your cholesterol and other risks during that 00:12:00.153 --> 00:12:02.328 time.” Work through the treatment transition. 00:12:02.605 --> 00:12:07.170 In the separate pregnancy-planning case, medication reconciliation starts with the actual drug 00:12:07.299 --> 00:12:10.917 and indication. The vignette does not name a product or dose, so 00:12:11.003 --> 00:12:12.944 do not invent either in the referral. 00:12:13.349 --> 00:12:17.232 Ask the prescriber to agree on a plan before conception, document who 00:12:17.275 --> 00:12:20.101 will explain it, and specify how it will be revisited. 00:12:20.410 --> 00:12:23.354 The pregnancy plan belongs in the prescribing record as well as the 00:12:23.397 --> 00:12:27.962 obstetric record. The FDA removed the blanket pregnancy contraindication for statins while 00:12:28.005 --> 00:12:31.452 continuing to advise discontinuation in most pregnant patients. 00:12:31.742 --> 00:12:36.244 A small group with very high cardiovascular risk may require individual assessment. 00:12:36.478 --> 00:12:39.977 This change does not establish safety for every lipid drug or support 00:12:40.190 --> 00:12:44.143 routine statin use in pregnancy. When ongoing statin treatment is required after 00:12:44.272 --> 00:12:50.373 delivery, FDA advises against breastfeeding. Discuss feeding and cardiovascular treatment together. 00:12:50.629 --> 00:12:55.856 Return to Maria. Record Maria’s preferences, agreed prevention plan and the clinician 00:12:55.942 --> 00:13:00.293 who will reassess her response. Pregnancy history can improve the conversation without 00:13:00.464 --> 00:13:04.292 becoming a reason to overtest or to promise an unproven therapy. 00:13:04.537 --> 00:13:08.462 The takeaway from this case: Record the pregnancy history without labeling it 00:13:08.547 --> 00:13:14.364 an atherosclerotic cardiovascular disease event. Complete current risk information before choosing treatment. 00:13:14.635 --> 00:13:17.456 Include reproductive plans in medication decisions. 00:13:18.042 --> 00:13:21.712 For the third case, the clinical setting changes to secondary prevention. 00:13:22.010 --> 00:13:24.592 Residual risk after a myocardial infarction. 00:13:24.831 --> 00:13:28.946 Elena is 58, has type 2 diabetes, and had a myocardial infarction 00:13:29.156 --> 00:13:31.508 two years ago. She is postmenopausal. 00:13:31.760 --> 00:13:36.001 L D L cholesterol is 92 milligrams per deciliter while prescribed a 00:13:36.044 --> 00:13:40.463 high-intensity statin. She also reports preeclampsia many years earlier. 00:13:40.778 --> 00:13:45.863 The current decision is secondary prevention for established atherosclerotic cardiovascular disease. 00:13:46.033 --> 00:13:49.099 Her pregnancy history remains part of her record, but it does not 00:13:49.225 --> 00:13:53.671 replace the evidence-based treatment pathway for her myocardial infarction and diabetes. 00:13:53.920 --> 00:13:56.765 Here is the decision. What is the best next step? 00:13:57.007 --> 00:13:59.482 Pause here if you would like a moment to think it through. 00:13:59.781 --> 00:14:03.535 The best next step in this case is: Confirm actual treatment use 00:14:03.621 --> 00:14:09.408 and response, address barriers, and choose additional evidence-based LDL lowering when indicated. 00:14:09.691 --> 00:14:13.829 Establish what Elena actually takes and tolerates, then act on the appropriate 00:14:13.915 --> 00:14:18.395 L D L cholesterol goal. The alternative can miss access, adherence or 00:14:18.437 --> 00:14:22.903 adverse-effect problems. The alternative can prolong avoidable residual risk. 00:14:23.229 --> 00:14:26.813 The guideline restores L D L cholesterol and non H D L 00:14:26.856 --> 00:14:31.763 cholesterol goals, including L D L cholesterol below 55 milligrams per deciliter 00:14:31.891 --> 00:14:37.453 for very-high-risk atherosclerotic cardiovascular disease. Confirm that Elena meets the full criteria 00:14:37.624 --> 00:14:42.402 before assigning this category; a prior myocardial infarction and diabetes alone do 00:14:42.445 --> 00:14:47.447 not establish multiple high-risk conditions. Apply the appropriate secondary-prevention pathway. 00:14:47.713 --> 00:14:53.089 Select additional treatment using the reduction needed, outcome evidence, safety, patient preference 00:14:53.217 --> 00:14:58.912 and access. Maximally tolerated statin. Reason to discuss it: Foundational therapy in 00:14:58.955 --> 00:15:05.909 appropriate atherosclerotic cardiovascular disease care. Question before selecting: Actual use, symptoms, interactions 00:15:06.251 --> 00:15:11.608 and response?. Ezetimibe. Reason to discuss it: An oral nonstatin option for 00:15:11.651 --> 00:15:17.440 additional LDL lowering. Question before selecting: Enough reduction for the patient’s goal?. 00:15:17.624 --> 00:15:20.555 P C S K 9 monoclonal antibody. 00:15:20.840 --> 00:15:26.238 Reason to discuss it: Potent LDL lowering with cardiovascular outcomes evidence. 00:15:26.728 --> 00:15:30.995 Question before selecting: Access, administration and treatment burden?. 00:15:31.166 --> 00:15:35.624 Bempedoic acid. Reason to discuss it: Oral option with outcomes evidence in 00:15:35.667 --> 00:15:41.896 studied statin-intolerant patients. Question before selecting: Indication, adverse effects, interactions and current 00:15:41.982 --> 00:15:47.127 label?. Inclisiran. Reason to discuss it: LDL lowering through a different dosing 00:15:47.341 --> 00:15:52.802 approach. Question before selecting: Do not equate lipid efficacy with completed event-outcome 00:15:52.845 --> 00:15:57.472 evidence; check current data. This comparison supports a treatment discussion; it does 00:15:57.514 --> 00:16:00.117 not establish a preferred product for every patient. 00:16:00.544 --> 00:16:03.146 Review current prescribing information before use. 00:16:03.488 --> 00:16:06.184 Turn the L D L cholesterol result into a decision. 00:16:06.406 --> 00:16:10.382 “Prescribed a high-intensity statin” is not the same as taking and tolerating 00:16:10.510 --> 00:16:14.435 it. Ask Elena to describe the medicine, dose and schedule she actually 00:16:14.691 --> 00:16:19.707 uses. Explore symptoms without dismissing them, and distinguish a clinical adverse effect 00:16:19.835 --> 00:16:21.968 from an affordability or refill problem. 00:16:22.309 --> 00:16:25.637 Review other causes of an inadequate lipid response and agree on a 00:16:25.680 --> 00:16:29.759 feasible regimen. If actual use is confirmed and L D L cholesterol 00:16:29.845 --> 00:16:34.751 remains above the appropriate goal, discuss additional LDL-lowering therapy using the size 00:16:34.837 --> 00:16:38.401 of reduction needed, the evidence for her clinical setting and the practical 00:16:38.529 --> 00:16:42.582 burden of treatment. An oral agent and an injected agent may present 00:16:42.753 --> 00:16:47.218 different adherence and access issues. A lower laboratory value is useful only 00:16:47.346 --> 00:16:49.415 when the plan can be implemented and reviewed. 00:16:49.650 --> 00:16:51.741 Benefits and harms belong in the same discussion. 00:16:51.954 --> 00:16:56.553 CLEAR Outcomes reported more gout and cholelithiasis with bempedoic acid than placebo. 00:16:56.885 --> 00:17:01.280 The current FDA label warns about hyperuricemia and tendon injury and includes 00:17:01.365 --> 00:17:06.187 drug-interaction precautions. Ask about relevant history and review the exact current label 00:17:06.357 --> 00:17:11.496 before choosing treatment. These considerations accompany the cardiovascular result rather than disappearing 00:17:11.752 --> 00:17:13.544 because a trial met its endpoint. 00:17:14.056 --> 00:17:16.339 Check the endpoint before recommending a medicine. 00:17:16.531 --> 00:17:24.523 What the trials establish. CLEAR Outcomes randomized 13,970 statin-intolerant patients with or 00:17:24.651 --> 00:17:29.430 at high cardiovascular risk. The primary composite occurred in 11.7 percent with 00:17:29.516 --> 00:17:36.362 bempedoic acid and 13.3 percent with placebo; hazard ratio 0.87, 95 percent 00:17:36.575 --> 00:17:42.634 confidence interval 0.79 to 0.96. These findings support an option for the 00:17:42.677 --> 00:17:47.390 studied population. They do not demonstrate safety in pregnancy or a benefit 00:17:47.518 --> 00:17:54.470 specifically after preeclampsia. VESALIUS-cardiovascular studied evolocumab in patients with atherosclerosis or diabetes 00:17:54.555 --> 00:17:58.566 who had no previous myocardial infarction or stroke and found fewer first 00:17:58.651 --> 00:18:03.406 cardiovascular events than placebo. “No previous myocardial infarction or stroke” does not 00:18:03.491 --> 00:18:08.483 mean a healthy, low-risk population. Elena already has a prior myocardial infarction, 00:18:08.739 --> 00:18:11.299 so this trial should not be presented as a direct match to 00:18:11.342 --> 00:18:17.205 her history. In September 2026, Novartis reported that pelacarsen lowered lipoprotein a 00:18:17.247 --> 00:18:22.567 in lipoprotein a HORIZON but did not meet the primary cardiovascular endpoint. 00:18:22.895 --> 00:18:27.290 This is a sponsor topline announcement; detailed methods and results require appraisal 00:18:27.333 --> 00:18:31.100 when available. Pelacarsen remains investigational in this report. 00:18:31.496 --> 00:18:35.506 Lowering a biomarker does not by itself establish clinical benefit, and one 00:18:35.592 --> 00:18:37.981 trial does not establish a class-wide conclusion. 00:18:38.194 --> 00:18:42.103 Here is the decision. Elena asks whether a large fall in lipoprotein 00:18:42.145 --> 00:18:46.220 a means an investigational medicine will prevent her next myocardial infarction. 00:18:46.455 --> 00:18:49.143 Which answer is best? Pause here if you would like a moment 00:18:49.313 --> 00:18:52.067 to think it through. The best next step in this case is: 00:18:52.195 --> 00:18:56.888 “We need cardiovascular outcome results for the particular treatment and population while 00:18:56.931 --> 00:19:01.183 treating the risks we can address now.” The alternative substitutes a biomarker 00:19:01.226 --> 00:19:05.876 response for a clinical outcome. The alternative overgeneralizes one trial to a 00:19:05.919 --> 00:19:12.475 whole class. Check the population, comparator, endpoint, absolute effect, uncertainty and harms. 00:19:12.801 --> 00:19:15.550 Consider absolute effects as well as the headline. 00:19:15.825 --> 00:19:21.116 In CLEAR Outcomes, subtracting 11.7 percent from 13.3 percent gives an absolute 00:19:21.329 --> 00:19:25.340 difference of 1.6 percentage points in the primary composite over the trial 00:19:25.382 --> 00:19:30.988 follow-up. The hazard ratio of 0.87 is a relative time-to-event comparison; it 00:19:31.030 --> 00:19:33.804 is not a 13-percentage-point absolute reduction. 00:19:34.102 --> 00:19:36.757 Neither number predicts Elena’s individual benefit. 00:19:37.066 --> 00:19:41.418 The studied population, background care and follow-up must remain attached to the 00:19:41.461 --> 00:19:44.974 estimate. A composite endpoint combines several outcomes. 00:19:45.287 --> 00:19:49.554 Check which components changed, how harms were collected and whether follow-up was 00:19:49.596 --> 00:19:53.091 sufficient for the question. Do not infer a proven benefit for women 00:19:53.261 --> 00:19:57.827 with prior preeclampsia from an overall result unless an applicable analysis supports 00:19:57.912 --> 00:20:02.162 that claim. This activity uses trials to practice appraisal, not to create 00:20:02.290 --> 00:20:05.975 a pregnancy-specific treatment indication. Elena’s next visit. 00:20:06.289 --> 00:20:10.257 Agree on the treatment decision and review interval with Elena, document access 00:20:10.428 --> 00:20:15.633 arrangements, and name the clinician responsible for reassessing adherence, tolerance and laboratory 00:20:15.718 --> 00:20:19.075 response. Ask her to explain the plan in her own words. 00:20:19.501 --> 00:20:22.893 A prescription without access or follow-up is an incomplete plan. 00:20:23.256 --> 00:20:27.125 The takeaway from this case: Distinguish prescribed treatment from actual use. 00:20:27.453 --> 00:20:30.461 Apply evidence from the appropriate patient population. 00:20:30.994 --> 00:20:33.804 Agree on an accessible treatment and follow-up plan. 00:20:34.350 --> 00:20:38.061 Before you go, bring the three cases back to one question: what 00:20:38.104 --> 00:20:39.854 will you do differently at the next visit? 00:20:40.238 --> 00:20:43.630 Ask what happened in pregnancy. Assess the risk that exists today. 00:20:43.907 --> 00:20:46.057 And make the next step someone’s responsibility. 00:20:46.287 --> 00:20:50.639 You’ll find the source references, transcript and clinical resources beside this episode. 00:20:51.066 --> 00:20:54.266 To record your answers and complete the learning activity, return to the 00:20:54.309 --> 00:20:56.944 activity page for the questions and brief evaluation. 00:20:57.318 --> 00:20:59.558 This has been HEART RESERVE Clinical Conversations. 00:20:59.835 --> 00:21:02.012 I’m Lisa Zahakos. Thank you for listening.