Links to My Recent Writing and Speaking

I have been busy writing. Here is a summary and links.

Oct 02, 2024

Statin Use and the New Risk Calculator

People overthink statin drugs. It is actually simple: you use an online calculator to get your 10-year risk of a heart attack or stroke. Then you multiply that by the statin risk reduction of 0.25, which comes from oodles of trials. If the absolute risk reduction is to your liking, you take a daily pill. If not, you don’t take the pill. Statins, in my opinion, could be over-the-counter. Few decisions in medicine are more preference-sensitive.

The big development this year came when the American Heart Association introduced a new risk calculator, called the PREVENT score. They said it was a more accurate score. That sounds great; the problem is that it kicks out lower 10-year risks than the present risk calculator. Fewer people reach the doctor-derived threshold for statin use at ≥ 7.5% over 10-years. PREVENT creates angst in some doctors because it decrease the numbers of “statin-eligible” patients.

The title of my column is Did Statin Decision-Making Just Get Harder?

Beta-Blockers After MI Challenged

One of the stickiest dogmas in cardiology is that patients who have myocardial infarction (MI, or “heart attack”) should take beta-blockers, which block the effects of adrenaline. The evidence establishing post-MI beta-blockers came from trials done in the 1980s. JAMA published the positive BHAT trial in 1982.

The care of patients with MI has radically changed. We now open occluded arteries and often stop MIs from causing damage. This change likely reduces the benefit of adrenaline blockade. Indeed, the REDUCE-AMI (circa 2024) trial of beta-blockers post MI failed to show a benefit of beta-blockers in patients with preserved ventricular function.

This fall, the ABYSS trial of beta-blocker interruption vs continuation in post-MI patients appeared to contradict REDUCE-AMI. ABYSS reported that the interruption arm did not reach noninferiority compared to the continuation arm. But. But. When you look closely at the results, ABYSS confirmed REDUCE-AMI, and, actually supported non-use of beta-blocker after MI in selected patients.

The title of my column on ABYSS is Beta-Blockers Post-MI? No for Me, Even After the ABYSS Trial

The Mystery of Clipping a Leaky Mitral Valve for Heart Failure

In heart failure due to reduced pump function, the left ventricle dilates. Dilation helps maintain cardiac output but it also spreads open the mitral valve—which prevents the leaflets from closing. Mitral regurgitation (MR) is bad because blood that should be going out to the body regurgitates back to the left atrium.

Medical students are taught that this “secondary MR” is an LV problem not a valve problem. When the MITRA-FR trial found no difference for transcatheter edge-to-edge repair (TEER = MV clipping) vs medical therapy, no one was surprised, including me. The surprise came weeks later when the COAPT trial of TEER vs meds found that the clip was amazing—almost as good as clean drinking water.

Proponents argued that you should not be perplexed by the divergent trials because COAPT trialists enrolled patients most likely to benefit. Their argument required high levels of trust in measurements from ultrasound images. Aka—”shadows.” They might be right, but I am not sure.

At the ESC meeting in August, we learned the results of RESHAPE-HF—the third trial comparing TEER vs medical therapy for patients with secondary MR. The trial returned positive results; proponents rejoiced. (MV clipping is lucrative and sort of fun to do).

My column, titled, TEER in Functional MR: Data Deluge, but No Easy Answers, offers six reasons to be cautious about the positive RESHAPE-HF results.

Guidelines Probably Do Not Apply to Older Patients with Frailty

My group is participating in an exciting new trial called Left vs Left. We will test two ways to use cardiac resynchronization therapy in patients with heart failure. We have already learned a lesson: trials have robust inclusion and exclusion criteria. In our first month, we’ve screened many more patients than we have enrolled. The most common reason to exclude a patient from the trial is multimorbidity and older age.

Translating evidence from trials, which enroll younger patients with less comorbidity, to older patients with multimorbidity, is the modern doctor’s greatest challenge.

The SENIOR-RITA trial stands out because the authors specifically targeted older patients who presented with MI. The current dogma for treating patients with non ST-segment elevation MI (so called NSTEMI) is to use an early invasive approach, where patients go to the cath lab for diagnosis and treatment (usually stents). Previous trials—which enrolled younger patients—found a slight advantage to early invasive over a conservative medicine-first strategy.

The title of my column: SENIOR-RITA: Old, Frail Patients: Study More, Intervene Less?

It Took Two Decades and Millions of Procedures But We Finally got a Proper Placebo Controlled Trial of AF ablation

In drug trials, we blind patients to their treatment arm to isolate the physiologic effects of the drug—not its placebo effect. But this is rarely done for procedures. Until this summer, nearly all trials comparing AF ablation had one arm in which patients got the procedure and the other group got tablets and no procedure. (You might say the control arm was ablation-subtracted.)

Well known is the fact that procedures put out a much stronger placebo effect than tablets. The first ORBITA trial shocked the cardiology world when it failed to find a placebo-resistant effect of stenting substantial coronary lesions.

This raises the question as to whether the improved quality of life in the ablation arm of trials was due to AF reduction or placebo effect or both.

The SHAM-PVI trialists boldly tested a standard AF ablation by a cryoballoon vs a sham procedure. My column is titled: AF Ablation Works…But: The Positive SHAM-PVI Trial

Besides being a columnist for TheHeart.org | Medscape Cardiology, there are five other places you can find my work.

Podcast:

The This Week in Cardiology Podcast comes out every Friday afternoon. I review the top 3-5 cardiology stories/studies of the week. Medscape cardiology posts the unedited transcript along with audio. You can also listen on most of the major podcast platforms, such as Apple podcasts and Spotify

Sensible Medicine

Along with Drs. Adam Cifu and Vinay Prasad, I co-edit Sensible Medicine—a site where we report and opine on medical stories without industry advertisement. I write a Study-of-the-Week column on Mondays.

Cardiology Trials Substack

Drs. Andrew Foy (Penn State) and Mohammad Ruzieh (University of Florida) and me are writing a book on Substack. The idea is create a reference book of all the seminal trials in cardiology. We post summaries of two trials per week—along with a podcast discussion of these. Instead of sending a completed manuscript to a publisher, we will write the book gradually on Substack. Take a look at Cardiology Trials.

Academic Publishing

I am now up to a modest 76 peer-reviewed co-authored papers. My latest was a piece on conflict of interest. In 2022, I authored an opinion on AF screening in the New England Journal of Medicine.

Public Speaking

I will have a busy rest of the year. I travel to British Columbia, Southern Poland, Switzerland, and Curitiba, Brazil to speak on various topics. I have agreed to give Cardiology rounds next year at the prestigious University of Michigan. And this Spring, I spoke at the Beth Israel Deaconess department of cardiology at Harvard Medical School.

But. But. I most enjoy my job as a practicing electrophysiologist in Louisville. It’s better now than it has ever been. Better because we are on the cutting edge of conduction system pacing. And, we are, like many American docs, beginning to use pulsed field ablation for AF.

Thanks for reading. Stop and Think will always remain free of ads. A special thanks to those who choose to be paid subscribers. I am grateful.

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