Even gazing at his face on the computer screen, I could feel his concern. He was 21 years old and seeking a consult with a cardiologist. He was not worried about a problem he had at the moment, but his future. In this horrific time of the COVID virus, this young college student applying to medical school was aware of the much greater and longstanding pandemic—the heart attack.

His father, age 62, had already had 2 heart attacks (myocardial infarctions) and five “stents” placed inside of the arteries of his heart. The young man had seen doctors in the last few months about sinus problems, and on 3 occasions he was told that he had high blood pressure. His family doctor had ordered recent blood tests for him and told him that his cholesterol was “a little high.” He wanted to know if I could help him avoid the fate of his father as he got older. I was confident that I could.

In reality, his father was fortunate. He had suffered from heart attacks due to a buildup of cholesterol inside of his heart arteries but had survived. So far, he had avoided the final wrath of what cardiologists called “The Widowmaker.”

I first heard the term Widowmaker when I was a medical student, struggling to learn to deal with the loss of too many of the heart attack patients I was seeing in the hospital. Many of these unfortunates were men who had a severe blockage of cholesterol and a blood clot in the major artery of their heart, their condition often unrecognized until the blockage was complete, and destroyed the heart muscle beyond repair. The result was a heart attack, often resulting in sudden death from abnormal electrical changes in their scarred heart muscle, or a chronic heart muscle malady, a condition known as congestive heart failure.

I have spent the last 40 years chasing the Widowmaker. The advances in the knowledge and success of how to treat and prevent the heart attack have been breath-taking. My career on the “frontline” of the emergency room and the cardiac care unit has brought me enormous satisfaction, allowing me to save so many lives and also educate younger physicians in the science and art of cardiology. But I didn’t think I was finished. I want to share my knowledge with as many people as possible.

Often medical facts are too cold and abstruse for the uninitiated in the medical sciences to absorb and apply to their own lives and care. Below are some key things you need to be aware of so you can remedy the malady, avoid the Widowmaker, and maintain good health.

Three untold signs that are overlooked that could be critical warning of arteriosclerosis of the heart’s arteries:

Mild heaviness in the chest, neck, or both arms either at rest or with exertion.

Shortness of breath with your normal activities.

Intermittent fluttering of the heart felt in your chest.

The role cholesterol plays in atherosclerosis:

We can’t live without cholesterol! It serves as the building block for the walls of the cells of the body; but too much ends up inside of arteries, like spackling compound on drywall. It’s this buildup that leads to blood clots forming that eventually will completely shut off blood flow and result is a heart attack. Cholesterol buildup comes from two sources – our diet and our genetics.

Three ways to lower cholesterol and blood pressure:

Eat better! Much less salt, less fat and carbohydrates—just less calories.

Exercise has so many great effects on health, but you need to get your heart rate up and sweat!

For many of us, medications are needed. They work as long as we take them regularly.

If your doctor orders a stress test, you should ask these 3 questions:

What exactly will the doctor learn about my heart from the test? Is there a blocked artery causing my symptoms, or not?

How accurate are the stress tests? Might I need more testing after the stress test, and if so, what tests would be necessary?

If I have an orthopedic problem, is there another test that could be done so that I don’t need to exercise and risk injury to my hip, knee, back, or ankle?

Anyone who is concerned about the heart health of themselves, a friend, or a loved one will benefit greatly by knowing this history and science of the human heart. I give much credit to the young patient proactively addressing his potential fate of his father. My potions will bludgeon his high blood pressure and drain the dreaded cholesterol from his blood. His heart will be protected.

Arnold Meshkov, MD, is a cardiologist, heart health expert, and was a professor of medicine at Temple University School of Medicine until 2015 when he returned to private practice. He is Board Certified in Internal Medicine, Cardiology and Echocardiography and has lectured on a broad range of topics in cardiology and bioethics, both locally and nationally. 

The views expressed in the article represent those of the author, not necessarily those of the publication.

Clinicians and experts interested in responding to this piece, or submitting their own articles to

A longtime clinician writes on the signs and risks of fatal heart attack events, including the Widowmaker.

Heart Education: Knowledge Saves Your Life

Arnold B. Meshkov MD, FACC

Panelists discuss the critical role health care providers play in raising awareness about alopecia, emphasizing strategies for effectively informing patients about the importance of early diagnosis and available treatment options.

The Role of Health Care Providers in Raising Awareness About Alopecia Areata

Video content above is prompted by the following:

Increased awareness about alopecia may lead to earlier diagnosis and more effective treatment options. What role do health care providers play in raising awareness about alopecia?

How can health care providers effectively inform patients about importance of early treatment and treatment options?

Healthcare providers play a crucial role in raising awareness about alopecia by educating patients on the condition's early signs and potential treatment options. They can effectively inform patients by integrating discussions about alopecia into routine check-ups, utilizing educational materials, and leveraging digital platforms to reach a broader audience. Providers should emphasize the importance of early diagnosis and intervention, which can lead to more effective management of the condition. By fostering open communication and providing comprehensive information, healthcare professionals can empower patients to seek timely treatment and improve outcomes.

Brittany G. Craiglow, MD

A method using solid-phase microextraction–liquid chromatography-mass spectrometry (SPME-LC-MS) was able to detect fatty acids and similar lipids that may help differentiate patients with psoriasis and 

. This is according to a small study published in

In this Q&A, corresponding author Vinod Chandran, MBBS, MD, DM, PhD, associate professor at the University of Toronto and director of the psoriatic arthritis program at the Schroeder Arthritis Institute in Toronto, discussed the research and its findings.

The researchers aimed to develop an LC-MS method to be used in combination with SPME to analyze fatty acids and similar molecules. They tested 25 chromatographic methods based on published lipid studies on two LC columns. As a proof of concept, serum samples from 27 patients with psoriasis (51% female, mean age 43 years), 26 patients with PsA (46% female, mean age 47 years), and 25 health controls (40% female, mean age 48 years) were processed using SPME and run on LC-MS. The best method for analyzing fatty acids and fatty acid-like molecules identified 18 compounds that were statistically significant between patients with psoriasis and those with PsA.

Approximately a quarter of patients with psoriasis have PsA. There is strong interest in discovering predictive biomarkers for patients with PsA among those with psoriasis, to shorten the time to diagnosis and management.

Metabolomics provides a powerful platform for identifying biomarkers for a complex, multifactorial disease such as PsA. Previous studies have reported examples of lipid dysregulation in serum taken from patients with PsA. Additionally, the high prevalence of metabolic syndrome and cardiovascular events in these patients makes lipids of key interest in psoriatic disease.

We sought to develop a metabolomics method using SPME-LC-MS to analyze serum lipids and identify any significant differences between patients with PsA and those with psoriasis.

What were the surprises from the findings?

The method we developed and optimized was capable of detecting lipids. Several classes of lipids such as acylcarnitines, lysophospholipids, and sphingolipids were significantly different between the patients with psoriasis and those with PsA. Specific focus was placed on valerylcarnitine, due to its confirmed identity using tandem mass spectrometry.

This is preliminary data that provides a good direction for future research in lipid biomarker discovery in psoriatic disease. We have developed and optimized a method that can be used on additional samples in a more expansive follow-up study.

What is the current practice and how could the findings possibly change things?

Currently, PsA is diagnosed in patients with evidence of an inflammatory articular disease, who meet certain clinical, laboratory, and imaging criteria. Patients with psoriasis are often screened at appointments with a dermatologist or general practitioner for signs of inflammatory arthritis.

Discovering accurate and reliable biomarkers for PsA could improve the ability of clinicians external to the field of rheumatology to identify patients with PsA. This may lead to prompt referral to a rheumatologist and early diagnosis and management of PsA by a rheumatologist.

What are the takeaway points for clinicians?

Emerging ‘omics’ sciences such as metabolomics have the potential to identify biomarkers that may aid in improving the diagnosis of PsA. Serum lipids such as valerylcarnitine have been found to be dysregulated in PsA. However, further research is needed to develop a biomarker panel to aid in clinical decision-making.

Koussiouris J, Looby N, Kulasingam V, Chandran V. A Solid-Phase Microextraction-Liquid Chromatography-Mass Spectrometry Method for Analyzing Serum Lipids in Psoriatic Disease. 

. 2023;13(8):963. Published 2023 Aug 20. doi:10.3390/metabo13080963

In this Q&A, Vinod Chandran, MBBS, MD, DM, PhD, discussed a method to analyze biomarkers that may differentiate patients with psoriasis and psoriatic arthritis.

Q&A: The Role of Metabolomics in the Diagnosis of Psoriatic Arthritis

Katie Robinson

 That’s a great segue into the last segment of our discussion, which is a mixture of core questions for us to summarize where we’re at and what we’ve discussed through this session.

Let me start off. Lisa, discuss how and when you decide to make a change in therapy.

 For me, it’s pretty straightforward. If I can’t get a patient clear or keep them clear, then I’m going to be discussing and encouraging a change because I want to make these patients’ lives better. I want to make them look better, feel better, and do better. If I can’t get them clear or keep them clear, we should try something different. Fortunately, our option list is growing longer by the day.

 What else? Are there other times you’d like to make a change in therapy? I’m not big on changing it because someone else already used it. About half the time, people come in and they just haven’t used enough of a medicine. I don’t necessarily write a new script, I just write a more detailed care plan and do volumetric prescribing, where I tell them a certain volume. In all of medicine but especially in dermatology conditions, what’s needed in each room isn’t just walking in, making the diagnosis, and prescribing something. Partially our decision about when to change therapy and how we change therapy is individualized according to what that particular patient might need.

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 and other great content in your inbox. Thank you.

A brief discussion on when it is best to switch therapy while treating patients for atopic dermatitis.

When to Change Therapy for Atopic Dermatitis

Lawrence Eichenfield, MD

01:43 Treatment landscape of rheumatoid arthritis

08:30 Use of TNFi in rheumatoid arthritis

12:33 Switching from TNFi in rheumatoid arthritis

20:16 Variations in the use of step therapy between states

27:09 Administrative burden of step therapy

32:20 Processing of exceptions to step therapy protocols

33:44 Step therapy in rheumatoid arthritis

36:45 Impact of staying on ineffective RA treatments

41:20 Use of molecular signature response classifier (MSRC) in RA

42:58 Step therapy and use of molecular signature response classifier (MSRC) test in clinical practice

46:12 Advice for patients and HCPs in navigating step therapy protocols

In this MEDcast episode, Drs Soloman, Sharobeem, Boone and Feldman discuss the use of step therapy in rheumatoid arthritis, how step therapy was intended to be used, how it is actually used, and challenges and solutions to its use.

Challenges With Step Therapy Protocol in Treating Rheumatoid Arthritis

Madelaine Feldman MD, FACR

 Dr Smith, from a physician’s perspective, what take-home messages do you want to share with our audience?

 The patients have done an excellent job saying what self-care patients need to do to make sure they don’t get the complications of the disease. You heard the science. You heard Sickle Cell 101. You’ve got to drink fluids to keep the cells from sickling. You have to stay hydrated. You have to get oxygen in your body to keep the cells from sickling. Don’t climb mountains and don’t scuba dive, because that’s going to cut your oxygen. If you’re going to fly, you might want to take oxygen with you.

You’ve heard them say, “Eat your vegetables.” That was pretty profound. Diet matters. Folic acid is a vitamin that patients with sickle cell disease take. You can get that in food. High-folate foods are important. A prudent diet is important because you want to keep your body well maintained. You heard, “Take your medicine.” These are all very basic but fundamentally important things. If you don’t like your medicine, talk to your doctor about it rather than just not taking it, because you could be doing damage to your organ. You might end up with something far worse than what you originally had. Take your medicines, and talk to your doctors about your medicines. Then seek out education.

I also want to talk to the people out there who don’t know their sickle cell status. They don’t even know if they have sickle cell trait. Please find out. Find out your sickle cell status. Get that hemoglobin electrophoresis done so you can say for sure whether you have the possibility of passing this disease on to your child. If you have sickle cell disease, you don’t need a hemoglobin electrophoresis to figure that out. There’s a possibility of you passing it along.

If you have sickle cell trait and you know it, you need to be sure before you have a baby that you have a discussion with your mate about whether they have sickle cell trait. Because the 2 of you, if you have it, may pass the disease along to your child. I’m not telling you not to have a child. I’m telling you to take everything with your eyes open. I want to make sure patients understand that we’re not telling them not to have babies, but we’re also telling them to be smart. There’s this phrase, “Be sickle smart.” To sum it all up, the patients have said it best. I’m not sure who originated this, but I heard a patient say, “I have sickle cell disease. Sickle cell disease does not have me.”

 Amen. That’s true. Do I have an agreement, Jamaal? Do you agree with that?

 We’re going to give Jamaal the last word because he’s the star of this show. Jamaal, you have a minute or so to tell the audience anything you want to share with us. We want to listen to you because you’re the rock star here. Go ahead and give us your words of wisdom for doctors, patients, advocates—anybody you want. You can do all of them.

 For the patients, I just want to say to listen to your doctors. Also, listen to yourself. Listen to your instincts and what your body is telling you. Always listen to that. For the doctors, I want to say to listen to your patients. Sometimes they don’t exactly tell you what’s going on. You may have to ask sometimes. Sometimes patients are looking for you to ask a little more.

 I would like to say thank you for supporting us. I would also like to say that sometimes you have to listen to your child also. Your child, especially with sickle cell, sometimes doesn’t like to tell you everything. You definitely have to listen to them and talk to them gently to make sure you get everything.

 Thank you so much, Jamaal. Your mama has heard you, because she brought that up first. She said, “Listen to your child.” You must have told her that before. She got that. Thank you so much. To sum everything up, it’s about listening. We have 2 ears and 1 mouth for a reason. Even though I like to talk a lot, I need to use my ears more as a physician. All providers need to use their ears more and also their eyes. You can listen with your eyes. You can sense by looking, perceiving, and watching when your patient has more to say, or when they’re not giving you all the information. That’s a skill. If you’re going to work in sickle cell disease, you really have to work up that muscle, where you’re listening with all your senses and not just your ears.

The goal of this meeting was for us to hear from you about how sickle cell impacts your life and how we can do a better job of supporting this community as providers and as a general population. Thank you so much. Thank you, Dr Smith. Thank you, Sherry. Thank you, Cassandra. And thank you so much, Jamaal, for giving us your time and attention. We appreciate you.

®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your in-box.

Wally Smith, MD, shares his take-home points for patients with sickle cell disease and urges to get tested for sickle cell trait.  

Physician Advice for Patients With SCD 

Sherry Bailey 

 Tonight, we're going to spend a little bit of time talking about an overview of age-related macular degeneration, diabetic macular edema, and then dive into some issues about improving outcomes through scientific innovation and focus specifically on faricimab or Vabysmo. As you all know, these are enormous public health issues. Neovascular AMD is the leading cause of precipitous visual loss in people over 60 in the United States, and diabetic macular edema contributes significantly to diabetic blindness, which is the leading cause of blindness in working-age Americans. Treatment with intravitreal anti-VEGF or VEGF inhibitors is the standard of care for both of these conditions, that is exudative AMD and diabetic macular edema. They're extraordinarily effective, but there are some barriers to outcomes that we're going to go over right now.

In the frame to your right, you can see an eye with diabetic macular edema, and this eye has most of the features of non-proliferative diabetic retinopathy, including hemorrhages, microaneurysms, exudates, and cotton wool patches, suggesting ischemia and edema. If you look closely at the center of the macula, you can see some early swelling in that color from this photograph. The question is, do patients in our clinics achieve the vision gains that we see in these clinical trials that Dr. Wells is going to explain to you shortly?

There are a number of papers and [research] projects that have looked at real-world medicine, real-world outcomes in patients with neovascular or exudative AMD. What they've shown is that eyes with this condition receive fewer injections in the real world than they do in the clinical trials. What does that mean? That means that patients in your office or in your local retina specialist's office should be getting a shot every month for years. But instead, what we know is that in the first year, only very few patients achieve an injection index that is a number of shots per year that's above, say, 10. Certainly very few get 12 or 13, and the majority achieve something like 7. And so why is that important? This is a paper from Tom Chula, and this is from pulled data that's anonymized from a number of retina offices. This type of data has been validated from the IRIS database from the American Academy of Ophthalmology and from Verona Health. It's been validated in Europe by a seminal publication by Frank Holtz, who showed that country by country vision goes down with a lower mean number of injections.

What are the challenges that patients encounter for monthly injections? Well, there are many. Some patients are just plain old non-compliant and some patients are very compliant. Patients encounter transportation issues, comorbidities. They're too sick to come in. They don't understand why they need to come in. It's expensive to come in. Travel may be expensive, co-pays may be expensive, and painful injections or fear of injections. There are also some challenges on the provider side. The provider needs to really engage patients around compliance, and that's something that we do a very strict job of. In practice in particular, most of the patients are monocular and many of them are physicians and many of them have failed to treat and extend in their first eye, and with AMD, they just don't catch up. If you treat and extend them and they lose vision or you PRN them and they lose vision, going back to monthly usually doesn't rescue them, at least in my experience. So we tend to be program monthly treaters, particularly for second eyes and particularly for eyes that are at risk and active. And that tends to be a lot of our patients at a tertiary center. But we do find the phenomenon that when we get patients seeing better they want to come in so we're not selling them on compliance we're selling them on better vision. And so these this is a set a typical set of challenges that patients encounter for a monthly injection burden.

Now, this leads to the second point of patients under clinic have suboptimal vision gains. And so, some years ago, novel therapies were looked at beyond just inhibiting vascular endothelial growth factor. And one of the pathways that was looked at inhibits angiopoietin 2, and the attempt to make more durable clinical effects with longer intervals between treatments and excellent safety, and in our hands, and Jack is going to talk to you all about this better vision.

Transcript is AI-generated and edited for clarity and readability.

Steven D. Schwartz, MD, reviews challenges and unmet needs in treatment of patients with neovascular AMD and DME.

Overview of Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema

Steven D. Schwartz, MD

Dermatologists Drs Tina Bhutani and Scott Boswell and patient Kanya Oul share resources and tools available to cope with generalized pustular psoriasis (GPP).

Tips for Managing Generalized Pustular Psoriasis (GPP)

This is a video synopsis/summary of a panel discussion involving Tina Bhutani, MD; J. Scott Boswell, MD; and Kanya Oul, RN.

In the concluding segment of the discussion, Kanya emphasizes the importance of healthcare providers listening to their patients and believing their experiences. She credits her doctor with saving her life and underscores the significance of finding a reliable healthcare provider who understands the patient's condition. Kanya encourages providers to educate themselves and be proactive in referring patients for appropriate care.

The speaker echoes the importance of education, stressing the need for healthcare professionals to stay updated on advancements in their field. He emphasizes the role of primary care physicians and emergency medicine practitioners in recognizing and treating severe skin conditions like generalized pustular psoriasis (GPP). The speaker shares his proactive approach to adopting new treatments for the benefit of his patients.

Overall, the discussion highlights the importance of patient-provider communication, education, and collaboration in effectively managing conditions like GPP. The participants express gratitude for the opportunity to share their insights, underscoring the value of such discussions in improving patient care.

Video synopsis is AI-generated and reviewed by HCPLive editorial staff.

Tina Bhutani, MD

Let’s shift gears for a few minutes to talk about safety. This came up earlier, we’ve been incredibly fortunate to have 2 agents come to us, in a fairly quick period of time, that have been incredibly effective and very safe for our patients, then stood the test of time for 15 years or so. Diana, are there specific considerations for your patients with diabetes as it pertains to safety? Are there factors that you discuss with them? Or do you approach them in a way similar to patients who need anti-VEGF therapy for other indications?

: We’ve learned over the past decade that interatrial VEGF inhibitors, such as aflibercept and ranibizumab, are extremely safe and effective. We’ve seen that across patient populations, whether it’s patients with diabetes, elderly patients with wet age-related macular degeneration [AMD], or patients with retinal vein occlusion, that the safety profile is consistent across these populations. I’m confident in recommending these treatments for patients with diabetic eye disease.

Let’s look forward into the future. There are a number of different agents for a variety of indications. We have biosimilars coming to the market. What’s going to be most important for you as you consider new therapeutic options in this space? Is it going to be the idea that we’re going to see dramatic improvements in efficacy? Or has safety suddenly become the No. 1 issue, given some of our recent experiences with new agents?

 I must say this has been a disappointing part of our field. We’ve had previous biologics that we looked at that were very efficacious, and because of the rates of inflammation, they did not get approved. It seems as though as we progress in our field, and we have longer-acting agents, this is something that has been a recurring thing. I’m hoping going forward our pipeline is pretty robust. We talked about the KIS-301 antibody biopolymer conjugate earlier today. We may have a PDS [port delivery system] that may be beneficial. There are other agents that may have great efficacy, and they may be a little bit more tolerable to the eye. The studies are ongoing, the preliminary data look good. If we can get the efficacy piece, and to decrease patient burden, to not have the inflammatory piece, that’s really great. It also may be true that it’s about time that we started having these discussions with patients about being comfortable with adverse effects. It’s amazing how cancer physicians prescribe all sorts of medicines, people lose their hair, they get ulcers, all these issues, and if they extend your life for 6 months, it’s a success. But we, as ophthalmologists, don’t like talking about intraocular pressure. We don’t like talking about cataracts. These are reversible, these are things that are treatable. If we’re going to try to maximize the efficacy in our patients by decreasing the unmet need, which is burden, we may have to start talking about some of the adverse effects that we often treat.

: Joe mentioned future agents KSI-301 and the PDS implant. The common thread with those 2 is that they appear to offer the opportunity for significant reductions in treatment burden with perhaps the same clinical efficacy as monthly injections of anti-VEGF therapy. It’s all the good that we get with progressive therapy with reduced treatment burden. That’s obviously an important unmet need in our space. What else would you identify as an unmet need? Or where should we move going forward to push the ball forward in terms of treating our patients?

 Longer term, our goals are obviously to improve efficacy. We care about vision at the end of the day. And ideally, we’d like a few therapeutic targets that we can potentially pair with our VEGF inhibitors to get improved visual acuity gains; reduced treatment burden obviously is a big thing. As far as what’s immediately on the horizon, as you alluded to, is going to be improving durability, reducing treatment burden while maintaining the same degree of vision gains. That being said, we’ve all experienced this in the last year, safety trumps everything now. That pendulum has swung to that extreme due to what we saw with brolucizumab. We saw what happened with abicipar as well. Biosimilars are right around the horizon. There are some potential theoretical and well-founded concerns about their safety in terms of the purification process of how these antibodies are made. Safety is the primary concern now. After that, hopefully, some of these new, longer-duration treatments are going to allow us to reduce injection burden. And deeper into the pipeline, when we look at some of the newer therapeutic targets, we’ll be able to even potentially improve vision further, or at least address some of these parts of the disease process, AMD atrophy for example, where we don’t have any treatment at all.

 And Diana, how about you? What’s the future look like for us as retinal physicians, and for our patients in managing retinal disease? What do we need to take better care of our patients?

: The future is very optimistic and bright because of new agents that are likely going to meet the burden of treatment and reduce the frequency of injections. Having the discussion of treating diabetic retinopathy when there is no vision loss yet, being more proactive, is going to be important. Because, as retina specialists, we do have approved agents that are safe and that can turn back the hands of time and decrease the risk of vision-threatening complications. There is going to be a paradigm shift in the future, and having these discussions will help facilitate that.

: To our audience, thank you very much for watching this 

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Key opinion leaders emphasize important considerations when discussing the safety of anti-VEGF agents with patients and highlight unmet needs in nonproliferative diabetic retinopathy treatments.

Initiating Conversations with Patients about Anti-VEGF Agents

W. Lloyd Clark, MD

Geoffrey Grammer, MD closes this series highlighting the administration options of esketamine, its safety profile, and the importance of monitoring patients using this treatment.

Authors