Real-World Insights: Navigating Cardiac Myosin inhibitors in Practice 

Anjali Tiku Owens, MD, shares insights into how their institution or clinic implements the Risk Evaluation and Mitigation Strategy (REMS) program for mavacamten, detailing the requirements and responsibilities of the patient in the process. Additionally, the expert draws upon their real-world experience with the cardio myosin inhibitor (CMI) in clinical practice, providing valuable perspectives on the practical application of this novel drug class.  

Anjali Tiku Owens, MD

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

 We’re going to bring our discussion to a close. Thank you all for this rich and informative discussion. Before we conclude, I’d like to hear final thoughts from each of you. Dr Amann?

 As Andy said, thank you, Mike, for sharing your personal story. Thank you too, Theresa, because you shared what it’s like being a parent of a child with ADHD [attention-deficit/hyperactivity disorder]. We’re appreciative of that as well. We change lives, and I’m ever grateful to all the resources I have to do that. It’s very rewarding to treat this disorder when it’s diagnosed and treated properly. Thank you to everybody for having me join this discussion. I’ve enjoyed it greatly.

 We’ve done a terrific job summarizing some of the issues. I feel so fortunate, like many of you, my colleagues. I’ve been working in this space for over 20 years, and [it’s so rewarding] to see the evolution of the technology and the different options, the understanding of the neuroscience of ADHD. It’s so rewarding to have all these different options.

I always joke that when you’ve seen 1 patient with ADHD, you’ve seen 1 patient with ADHD. We all know that. It’s so variable, the comorbidities and the daily activity. Having these tools and options allow us to do a much better job individualizing, personalizing, and getting better outcomes overall for our patients. I agree with Mike, it’s one of the more rewarding things that we treat in psychiatry. You can really make a difference. One thing that never gets old is helping a child and feeling like you can change the course of someone’s life and put them on a different track. That’s incredible. Mike used the railroad track analogy, which I love. That’s been very rewarding. We have a lot of challenges and a long way to go, but it’s been gratifying to see the progress we’ve made so far.

 For me, as a clinician in both settings, the most positive aspect is seeing self-confidence improve and children who are frequently getting in trouble and getting sent to the principal now getting merit reports saying that they’re the student of the day, and they aren’t getting in trouble anymore. With adults, like my patient who’s an attorney, the joy of watching somebody achieve their goals because they were willing to resume treatment is one of the most gratifying things about being a clinician.

Thank you so much for asking me to be here. It’s an honor to be here with many of my colleagues who are as old as I am, who have also treated folks with ADHD through their life span and have had the pleasure of seeing all the new developments in ADHD emerge and make a difference in people’s lives.

 Twenty years ago, I used to sit in the room with you for different meetings with all the teachers, moderators, and people I looked up to. You guys brought me into the world of validating this stuff and realizing how incredible this stuff was. I’m truly honored to be on the panel with you guys because I’ve always respected you. I might have been a little obnoxious in this [discussion], or a little restless.

 Maybe I interrupted a few times. But my biggest message is that this is a blast, but I hope people watch this and buy into what we’re saying.

 We understand. Thank you. Thank you again to our viewing audience. We hope you found this 

 discussion to be useful and informative. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming 

 and other great content right in your in-box. Thanks, everyone.

ADHD experts share their final thoughts on the treatment and management of ADHD.

Final Thoughts on Management of ADHD

Birgit H. Amann, MD

Masked Taper + CBT-I Helps Patients Rethink Sleep Med Needs, with Constance Fung, MD

sat down with Constance Fung, MD, MSHS, from the David Geffen School of Medicine at UCLA, to discuss her 

, “Impact of Benzodiazepine Receptor Agonist Masked Tapering Combined with Augmented CBTI on Daytime Sleepiness and Patient-Reported Sleep Quality.” During the interview, Fung shared how these findings inform deprescribing practices or guideline development for long-term benzodiazepine (BZRA) users with 

“We're really excited about the prospects of further implementing a masked tapering approach with augmented CPT-I,” Fung said.

Fung and colleagues created a Masked Taper plus cognitive behavioral therapy-augmented program (MTcap) to minimize placebo effects and boost discontinuation. A multi-site trial compared 8 weeks of MTcap with standard, gradual tapering in 188 adults aged ≥ 55 years (mean age, 69.2 years; 34.6%) female) who were on alprazolam, lorazepam, temazepam, or zolpidem for ≥ 2 nights per week and for ≥ 3 months. On average, participants used a BZRA 5.9 days a week.

In the study, MTcap resulted in greater BZRA discontinuation 6 months after treatment (73.4%) compared with standard tapering (58.6%). Insomnia severity improved for both arms, with baseline Epworth Sleepiness Scale scores increasing from 6.32 and 6.21 at baseline for MTcap and standard taper, respectively, to 3.98 and 3.92 at 1 week and 4.54 and 3.91at 6 months. Pittsburgh Sleep Quality index scores also showed improvements from baseline to week 1 and month 6 in both arms.

“I think one of the key elements of the masked tapering program was [that] we had this diary, and we'd ask people, what do you think you were taking on a [nightly] basis, compared to your baseline dose,” Fung said. “We're getting them to challenge their thoughts about their medication.”

Fung said she wants patients to ask themselves, “Is this pill really doing something for me?” After patients finish a MTcap program, they should recognize they are not sleeping well and maybe need a sleeping pill.

“I want them to be challenging that thought,” Fung said. “We'll need to do more analyses to try to get a better picture of exactly what was going on, but I really think that that is one of the reasons why the discontinuation rates were sustained long term.”

Fung has no relevant reported disclosures.

Ereso J, Alessi C, Martin J. Impact of Benzodiazepine Receptor Agonist Masked Tapering Combined with Augmented CBTI on Daytime Sleepiness and Patient-Reported Sleep Quality. Late breaker was presented at SLEEP 2025 the 39th annual meeting of the Associated Professional Sleep Societies, from June 8 – 11, 2025 in Seattle.

At SLEEP 2025, Fung discussed how combining a masked taper, CBT-I, and a nightly dose-tracking diary helped older adults achieve long-term benzodiazepine discontinuation.

Constance Fung, MD, MSHS

Part 5 of our 5-part panel discussion for CRC Awareness Month focuses on: Appropriate Guidance for CRC Screening Age/Role of Advocacy Organizations

Appropriate Guidance for CRC Screening Age, Role of Advocacy Organizations

This portion of our 5-part peer-to-peer discussion on the importance of colorectal cancer (CRC) screening focuses on appropriate guidance for screening age and the future of CRC advocacy in light of emerging technologies and evolving healthcare policies.

, as the experts discuss current and prospective age-based screening recommendations as well as the importance of both awareness and navigation of screening.

Sapienza introduces the topic and inquires about the experts’ reactions to suggestions for lowering the screening age to younger than 45 years, to which Imperiale says he is “horrified” and describes how this would likely lead to more harm than benefits. Instead, he suggests “doing things that make the most sense first,” like making patients aware of symptoms that warrant testing.

Colangelo then poses a question to Sapienza regarding his outlook on the future of CRC screening, advocacy, and support from nonprofit organizations, to which Sapienza describes the significance of both awareness and navigation efforts from the Colorectal Cancer Alliance, additionally calling attention to the important role of risk stratification.

Updates in Colorectal Cancer Screening Recommendations

Pressing Challenges in Colorectal Cancer Screening

Reaching Patients in Need of Screening for Colorectal Cancer

Navigating Patient Histories, Risk Factor Conversations in CRC Screening

 chief executive officer of the Colorectal Cancer Alliance, the largest colon cancer advocacy group in the country, and member of the American Cancer Society’s National Colorectal Cancer Roundtable steering committee.

, an internist, vice president, and chief quality officer for Premier Medical Associates, a large multispecialty group within Allegheny Health Network as well as a member of the American Cancer Society’s National Colorectal Cancer Roundtable steering committee.

 a gastroenterologist, associate division chief of the Department of Gastroenterology and Hepatology, and medical director of Endoscopic Innovations at Allegheny Health Network.

principal investigator of the BLUE-C trial, research scientist at Regenstrief Institute, and Lawrence Lumeng Professor of Gastroenterology and Hepatology at Indiana University School of Medicine.

Imperiale has no relevant disclosures to report. Colangelo has no disclosures to report. Relevant disclosures for Kochhar include CorEvitas Research, Eli Lilly, Boston Scientific Endoscopy, Olympus Endoscopy, and Pentax Endoscopy. Sapienza has no relevant disclosures to report.

In part 5 of our 5-part discussion, experts discuss their perspective on appropriate guidance for screening age and the future of CRC advocacy.

Gursimran Kochhar, MD

 What I’m hearing from you guys is that it’s important to educate your patients, to provide informed tools for them to make an informed decision based on their specific scenario. For our last question, I’m going to ask all of you: sickle cell disease has been around for over 100 years, and we’re still dealing with organ damage, acute exacerbations, quality-of-life issues, fatigue, difficulty finding a mate, difficulty finding work. What are your concerns around health equity and access to care that are persistent? What would be the 1 thing that if you could fix about sickle cell disease if you had a magic wand or a genie bottle? I’m going to have Dr Desai start, then Dr Shah and Dr Smith.

 I’m going to make the first wish. It’s to get every patient connected to some care—having somebody who will care and talk about these things, to say “I don’t know” sometimes and walk through life with them. We’ve talked about how complicated it is; they can’t do it by themselves. Everybody needs that advocate, they need the person that understands the disease. Even if they don’t understand, they’re willing to take that extra step. I wish everybody had a place that they could be connected to care.

 Excellent. Dr Shah, what’s your 1 wish from the genie bottle or magic wand?

 For wish No. 2, I have a 2A and 2B; they’re connected. The 2A is a big shift in mindset about therapies, from being reactive to prophylactic. We have drugs that are reactive because they’re anemic or because they have pain. But why do they have to be anemic or in pain? Why can’t we move more toward prophylactic? But because therapies are expensive, there’s so much out there, and not all patients are in centers that can give you those therapies, when we get to those therapies being prophylactic, they must be accessible, easy to take, and cost-effective. Not a drug that’s so expensive that a payer isn’t going to want to support that across the country. We have patients who aren’t plugged in to care, don’t have access to health care, and don’t have insurance. Why aren’t they getting the same therapy as another patient in an area that has a comprehensive sickle cell center? So there are 2 arms: better prophylactic medications with access to as many patients as possible.

 Public health. We don’t know how many patients have sickle cell disease in the United States, but Brazil does. Brazil is supposed to be an emerging nation. That’s a travesty. If we knew how many patients had sickle cell disease in every state in the United States, then we could more appropriately advocate for resources to do everything you just heard. We can know just by having somebody snap their finger and make each state share their newborn screening registry with each other; we could do that. Eleven states are already doing it, according to the CDC [Centers for Disease Control and Prevention]. My 1 wish is to get all 50 states to do that so we can talk intelligently about how many patients have the disease. We can then make health care allocation decisions for not just doctors but community health workers, hospitals with drugs, and community-based organizations and resources to help these patients.

 Thank you so much. My 1 wish is that all 3 of your wishes—or 3½ to 4 wishes—come true. If we get there, then each individual with sickle cell disease should be able to live to be 99 years old, get to lose all their teeth, and use a walker. Having a quality of life and a quantity of life that equals that of their peers is the ultimate goal.

I want to thank you, Dr Desai, Dr Shah, and Dr Smith. Thank you for this very informative session, for all your knowledge, and for sharing your experiences. This is a transformational period in sickle cell disease care. I look forward to more drugs being approved, I look forward to a lot more research, and I look forward to the 50 states being connected and for every patient to have access to the right type of care. Thank you very much, everyone.

Concluding their discussion on sickle cell disease management, expert panelists share key unmet needs and hopes for the future.

Sickle Cell Disease: Unmet Needs and Future Directions in Care

Ifeyinwa (Ify) Osunkwo, MD, MPH, Atrium Health

A subgroup analysis of the ICONIC-LEAD study had its findings presented at the World Congress of Pediatric Dermatology Annual Meeting, demonstrating that adolescents living with 

 given once-daily treatment with icotrokinra (JNJ-2113) saw increased rates of clear or almost clear skin at 16 weeks versus placebo.

After these data were released by Johnson & Johnson, the 

 editorial team interviewed Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego and professor of dermatology and pediatrics at the UC San Diego School of Medicine, who had been an investigator in this analysis. Here, Eichenfield highlights the study’s 

 and their significance for dermatologists.

Significance of Icotrokinra Findings for Adolescents with Psoriasis, with Lawrence Eichenfield, MD

“I think my big takeaway is that we have incredibly potent results in terms of this drug, with an incredibly good safety profile as well,” Eichenfield explained. “An easy number to walk away with is that there was almost 90% of patients made PASI 90 at 24 weeks, so we didn't even show PASI 75 data…It was 86.6% of patients at 24 weeks, it was 70.5% at the earlier time point of 16 weeks, and very low placebo response rate at 16 weeks.”

In the team’s other primary endpoint, which was an Investigator's Global Assessment (IGA) score of 0/1 (clear or almost clear skin) with a 2-grade improvement at least, 84.1% of subjects at the 16-week mark and 86.4% at the 24-week mark reported such a response.

“You have to mention the safety as well, and the data set is very consistent,” Eichenfield said. “The overall study population data set was as well, which [means there were] not a lot of remarkable adverse events. There happened to be 2 serious adverse events in the adolescent group, but neither of them was considered secondary to the drug. One patient temporarily stopped the drug and went right back on it. Another 1 had been hospitalized for an evaluation, but it was not related to the drug and never stop the drug. Otherwise, it was an unremarkable side effect profile.”

Eichenfield was asked about what these results should mean to dermatologists and health care professionals reviewing the data from his team’s analysis.

“The big picture is that this technology has set up essentially biologic-like efficacy in an oral agent,” Eichenfield explained. “Certainly for adolescent psoriasis with this particular drug, in this particular peptide, I think having the ability to get such rapid effectiveness with a great safety profile, without the need for injectables, and without concerns about blood work, it's really going to be incredibly well received by the dermatology community.”

View the full video posted above to find additional information on this segment of Eichenfield’s interview.

The quotes implemented in this summary were edited for the purposes of clarity. Eichenfield is a paid consultant for Johnson & Johnson.

Icotrokinra results show 75% of adolescents with plaque psoriasis achieved completely clear skin and demonstrate favorable safety profile in a once daily pill. Johnson & Johnson. April 10, 2025. Date accessed: April 11, 2025. 

https://www.prnewswire.com/news-releases/icotrokinra-results-show-75-of-adolescents-with-plaque-psoriasis-achieved-completely-clear-skin-and-demonstrate-favorable-safety-profile-in-a-once-daily-pill-302425136.html

This segment of the latest interview with Lawrence Eichenfield, MD, features a discussion about the ICONIC-LEAD study.

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

Data on JAK Inhibitor Safety for Those Pregnant or Breastfeeding, with Tina Bhutani, MD

American Academy of Dermatology (AAD) Annual Meeting

 in Orlando, a presentation titled ‘Alopecia Areata: New Therapies’ featured University of California, San Francisco clinical researcher Tina Bhutani-Jaqcues, MD, who spoke with the 

The topic of Janus Kinase (JAK) inhibitors and guidance on implementation among patients with 

 during pregnancy or breastfeeding was highlighted by Bhutani in her interview. Bhutani was asked about some of the biggest takeaways from the talk at AAD.

“I encourage, if you do have a patient who for whatever reason does become pregnant while on these medications or decides that they still want to breastfeed, despite the limited amount of data, to actually report this to the to the FDA and the company at large, so that we can track this data,” Bhutani said. “There are also registries. There's a registry called ‘MotherToBaby,’ and they track the effects of medications on pregnancy and lactation. So using those kinds of resources can help others, help to increase the numbers of patients that we have, and increase our confidence in using these medications in this population.”

Bhutani also highlighted several unique findings covered in her talk regarding JAK inhibitors and birth control among women.

“The other concern that comes up when we're treating women of reproductive potential is the question about birth control,” Bhutani said. “So we know that, for example, oral contraceptive pills can increase clotting risk in some patients, especially women who are age over the age of 35, especially if they're smokers and things of that sort. One of the concerns in that black box warning was the risk of venous thromboembolism or blood clots. So the question becomes if we combine JAK inhibitors with birth control, is that a double hitter, and are these women going to be at increased risk for blood clots? And the answer is actually no, not from the data that we see.”

Bhutani noted that these types of findings contribute to the safety profile of JAK inhibitors used for alopecia areata. She highlighted research on rheumatoid arthritis during which patients were allowed to continue birth control, with the results indicating that the risk of venous thromboembolism was not increased.

Later, Bhutani was asked about additional studies she highlighted in her talk. She noted an additional analysis that she felt was worth mentioning.

“I think one unique thing that [also] I found was that for deucravacitinib…in the animal studies, [investigators] actually didn't see any issues with the drug either crossing into the placenta or causing any abnormalities,” Bhutani said. “So I think it just it begs the question ‘Should it really be in the JAK family’ and ‘Is it a different type of protein?’”

For additional information on this topic, view the full video interview posted above.

The quotes contained in this summary were edited for the purposes of clarity.

This AAD 2025 interview with Bhutani covers some of the takeaways from her presentation on use of JAK inhibitors for alopecia areata among pregnant or breastfeeding women.

Tina Bhutani, 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