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.

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.