Things I have worked on in the last month

The main thing I do, of course, is my work as an electrophysiologist.

Pulsed field ablation has transformed AF ablation. It is fast, safe and has changed the calculus to recommend AF ablation. PFA is probably not any more successful, but it is less likely to cause the most dreaded complication—atrial-esophageal fistula.

On the pacing front, we continue to use conduction system pacing, which results in gorgeous paced QRS complexes, and likely avoids pacing induced cardiomyopathy. We are (proudly) randomizing patients in the Left vs Left clinical trial.

Honestly, it’s never been a better time to be a heart rhythm doctor.

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At Medscape

I wrote two new columns.

Cerebral Protection in TAVI: A Picture vs Thousands of Data Points explores the mystery of cerebral protection during transcatheter aortic valve implantation or TAVI. The short story: TAVI creates lots of debris during the procedure. The debris can travel north to the brain and cause stroke. A device placed in the carotids catches debris. Pictures show it. Yet three trials have found no significant benefit in stroke. How is that possible? Get this: an observational study may explain the mystery.

In CABG Still Superior to Stents Despite FAME 3 Endpoint Swap, I highlight the way proponents of a procedure can emphasize more favorable endpoints in a trial. We can treat symptomatic multi-vessel coronary artery disease with either percutaneous coronary intervention (with stents) or coronary artery bypass grafts (CABG). Numerous trials favor CABG. The FAME-3 trial also favored CABG in its 1-year results. Now, FAME-3 authors have published 3- and 5-year results, suggesting stents are equivalent. I explain why the results are actually the same as the 1-year results.

On the This Week in Cardiology Podcast

Apr 18, 2025 This Week in Cardiology Podcast. Further discussion of FAME-3, and TAVR vs SAVR at 5 years, pacers after TAVR, and mavacamten is not a wonder drug for all types of hypertrophic cardiomyopathy.

The Apr 25, 2025 This Week in Cardiology Podcast reported on AI and ECGs, a novel ways to treat hypertension, combined lipid-lowering therapy after myocardial infarction, PFA and silent stroke, a move toward accountability in AF ablation, and pacing issues in tricuspid valve replacement.

In the May 02, 2025 This Week in Cardiology Podcast, I commented on the recent FDA approval of TAVR for asymptomatic patients with severe aortic stenosis, digital health, the subcutaneous- vs transvenous ICDs and cryptogenic stroke in young adults. The PRAETORIAN XL trial was especially dubious.

In this week’s May 09, 2025 This Week in Cardiology Podcast, I covered the controversial KETO-CTA study, tough decisions in subclinical AF, and another potentially huge benefit for GLP-1 receptor agonists.

This Week in Cardiology comes out in any of your favorite podcast apps. The above Medscape links include a rough transcript.

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At the European Heart Rhythm Association (EHRA) Meeting in Vienna

I gave two lectures. In one I took the contra side of PFA. But it was really difficult because I am now using PFA for all AF ablations. Nonetheless, there is still uncertainty about the new technology.

In the other lecture, I spoke about caveats in separating statistical vs. clinical significance. I also chaired a session on leadless pacing.

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At the UMC Amsterdam

I flew from Vienna to Amsterdam to speak at UMC Amsterdam. The first thing to say is that UMC Amsterdam seems like the Mayo Clinic of the Netherlands. It’s huge. There are basic science labs a pedway walk from the hosptial wards. UMC Amsterdam has a deep history in cardiology. Total Excitation of the Human Heart is one of the seminal papers describing how the heart is activated.

As it was in Denmark, to become a Dutch cardiologist requires a PhD. There were 6 PhD candidates who presented their work. There are 3 slots in cardiology. These are impressive young people—who are achieving great things. Call me old school, but medicine should be this competitive.

I gave two talks. One on spotting methodological flaws in clinical trials, and the other, a critical appraisal of AF evidence with a focus on areas of uncertainty. The team also took me for a 60k bike ride in the Dutch countryside. It was incredible.

Over at Sensible Medicine

I usually write on Mondays in a column called the Study of the Week.

On May 5, the Perhaps the Strongest Benefit of GLP1a drugs is...column appraised the ESSENCE trial, using semaglutide to treat patients with fatty liver disease.

On April 28, in the Words can Harm, Words can Heal column, I wrote about one of my all-time favorite studies, from a single center and author. KB Thomas studied the value of being positive in clinical encounters. What an awesome study.

On April 21, I wrote about the PROTECT TAVI trial. It was similar to my column on TheHeart.org | Medscape Cardiology, only written for a more general audience.

On April 14, the Tech Bros Require Regular Relooks at the Seminal Evidence in Coronary Artery Disease column revisited the COURAGE trial, which provocatively showed that fixing severe coronary lesions did not reduce MI or death over simple medical therapy. I aimed to counter the movement pushed by technology billionaires that everyone should be screened for coronary disease.

We also have a new 20-week series of lectures on How Not to Get Fooled by Medical Literature. In this series, Vinay, Adam and I each present and discuss a pertinent topic in critical appraisal. Here is the first of 10 lectures. We plan to extend the series after these lectures.

Sensible Medicine is approaching 100,000 subscribers. It is super exciting. The Substack model allows us to remain independent, free of ads. The next challenge is that Vinay Prasad is leaving (for a while) to head up the CBER division at FDA. We enthusiastically endorse him, and, we also hope he brings added rigor to the regulatory process.

Over at Cardiology Trials Substack

I also work with Drs. Andrew Foy and Muhammed Ruzieh in our effort to chronicle all the seminal trials in cardiology. Each trial gets a 1200-word summary, and we do biweekly discussions in podcast format. We finished the acute MI section and are now onto heart failure.

There are too many posts to single out. But if you are interested in the evidence underpinning what we do in cardiology, Cardiology Trials is your place. I learn so much reviewing these older trials. The problem, of course, is some things cannot be unseen.

Next Meetings

I travel to the Berlin AF meeting in a couple of weeks. I will speak about one of the most flawed trials in all of electrophysiology—the OPTION trial. I will also present a lecture on critical appraisal of medical evidence.

In June, I will speak at the London Arrhythmia Summit.

Fitness Update

Training wise, I had a difficult winter with a bad crash in October, multiple viral infections, lots of travel and terrible weather in Kentucky.

I am doing better and our morning rides have begun. My goal at age 61 is to not get dropped on our Sleepy Hollow Climb, a 3:15 second effort at about 4-5% that requires about 350-400 watts to hold wheels.