Some Year End Things and A Pro-Tip
Here’s another update of things I’ve worked on.
My year end review of top cardiovascular stories is up over at TheHeart.org | Medscape Cardiology. We learnt quite a bit in 2025.
Two trials suggested less-is-more when it comes to combining anticoagulants and antiplatelet drugs when patients have chronic coronary disease and AF.
Beta-blockers used routinely after uncomplicated myocardial infarction is now completely reversed as multiple trials showed little to no benefit.
Asymptomatic carotid vascular disease in the US was often treated with surgery. The CREST 2 trial showed this practice was inferior to simple medical therapy.
The mantra in severe aortic stenosis was no intervention into symptoms. Key opinion leaders aim to change that; but their data is weak.
Radiofrequency energy in the kidneys to treat hypertension is set to be let loose to the profit-makers. Renal denervation is so bad it may make left atrial appendage closure look like a good deal.
One of my favorite stories was the failure of cerebral protection during TAVI procedures. How does a device that catches debris-heading-to-the-brain not reduce stroke?
I’ve watched my colleagues in AF ablation promise game-changing approaches for two decades. None really worked. Until now. Pulse field ablation is incredible. There is no going back to thermal ablation.
The German-led Closure AF trial showed inferiority of left atrial appendage closure compare to simple anticoagulation. The results aren’t published yet, but this shocked the proponents—who have largely remained silent.
I have always said TAVI is an amazing procedure. The question is whether low surgical risk patients should have TAVI or open heart surgical valve replacement. Five to seven year data came out in 2025 and TAVI looks pretty darn close to surgery. We await ten-year outcomes; I predict surgery will look better over time.
This year saw one of the goofiest change-in-endpoints I’ve ever seen. The FAME-3 trial found that bypass surgery beat stenting in its primary analysis. But after the loss, the authors changed the endpoint to one more favorable to stents. And. Voila. Now the two therapies look similar. Trigger warning: this cannot be unseen.
We also had two trials looking at stopping oral anticoagulants after successful AF ablation. Both trials were underpowered to tell any difference. But they were underpowered because stroke rates were so (awesomely) low. Which is an important knowledge pont.
Last Friday was the year’s last This Week in Cardiology podcast. I discussed how difficult it is to predict cardiac events, a trial with a really crazy endpoint, tirzepatide’s dominance over dulaglutide in diabetes, and the sorry saga of andexanet alfa—a reversal agent Factor Xa inhibitors , which was pulled off the market this year.
I also wrote about the mistakes made with andexanet alfa on Sensible Medicine’s Study of the Week. There are important lessons in critical appraisal.
Speaking of Sensible Medicine, Adam and I love the project. We miss Vinay, but he’s doing important work at FDA. It’s hard for me to believe that every post we send goes off to 103K subscribers. We are also excited to have Andrew Foy join us on our Fortnight podcasts. Andrew is one of the best thinkers in all of Medicine.
The Pro Tip
For cardiology learners or purists, please do look at our Cardiology Trials Substack. This is a project I work on with Drs. Andrew Foy, Muhammed Ruzieh. The idea is to write summaries of every seminal trial in cardiology. A place to go to read why we do the things we do. It’s a work in progress.
Ruzieh recently added a bonus: How To Read a Cardiology Trial. This is such an excellent piece.
December is a our busiest month in the hospital. It’s weird; this is my 29th year at Baptist Health Louisville. And I enjoy it now more than I ever have.
Specifically, PFA has transformed AF ablation and conduction system pacing makes the most beautiful ECGs. Generally, though, the work of helping people feels even better than it always has. I really do love it. We get paid to help people. That is nice.
Merry Christmas and Happy New Year. And thanks for reading my stuff.
Merry Christmas and happy new year John. You might add a summary point that if I recall correctly came from the house of God. The key to good healthcare is to quote " do as much nothing as possible" - that seems to be the mantra for a lot of these procedures and the layering of multiple drugs.
The one negative seems to me that our healthcare system either broke after Covid or it's one of those non-causal relationships.
In my retirement, I've almost become a full-time patient advocate. I don't know if it's because the physicians and team are so busy or I'm just getting selected people reaching out. It's kept me reading more than I did when I practiced and I can still feel useful. I have to leverage the kindness of my colleagues, although I send them very nice interesting and grateful people.
My best friend 72 ,developed new onset severe depression that was debilitating. He was self referred for IV ketamine. No one bothered with an exam labs, etc.. I pushed him to go to internal medicine and even gave him a note saying please do a CT. He was given Zoloft. A week later, his wife took him to the ER and the golf ball size glioblastoma was found. It wouldn't have made a difference. He passed away nine months later.
It taught me we are all one ultrasound away from devastation. Be kind.
Every week I get a phone call from someone who cannot get in. They are clearly ill, but not emergently so they don't want to go to the ER. The other version is they've been in and essentially have been blown off. They are all older individuals with a high pretest likelihood of real illness.
There is another tier of health healthcare that I was not even aware existed.
When we were working with our weight loss program, we came upon a program for high net worth individuals. (These patients are not doctors :)) .
They essentially have access to a 24/7 Medical concierge that bypasses the system for them, no matter where they are in the world. They get instant access to medical care in whatever setting is most efficient. Insurance is irrelevant for these individuals.
In the TV show "blacklist." James Spaders character has medical teams on standby that can convert a warehouse into an OR in a moment's notice.
I just didn't realize this was true!
Merry Christmas and happy new year and thank you for educating all of us. (and Festivus for the rest of us)
The airing of grievances ceremony of Festivus should be a required meeting between doctors and hospital administrators every season!
Such a demanding field, EP, both intellectually and physically. Yet you find time to write with elegant clarity. Hats off to you!