This Week in Family Medicine — Aug 30, 2026

Welcome to This Week in Family Medicine. This week we're covering seven notable papers spanning cardiovascular prevention and deprescribing, digital tools for changing patient and prescriber behaviour, and the evidence base underpinning contested clinical guidelines. Let's dive in.

We start with two trials that ask when cardiovascular drugs are genuinely needed. In The Lancet, Silvain and colleagues pooled individual patient data from the ABYSS and SMART-DECISION randomised trials — more than six thousand stable patients at least six months out from a myocardial infarction, with an ejection fraction of forty percent or higher and no heart failure and no other indication for a beta blocker. Median time since the index infarct was three and a half years, and patients were followed for three years. Stopping the beta blocker met the prespecified non-inferiority criteria both for the composite of death, infarction, stroke or cardiovascular hospitalisation, which occurred in about seventeen percent of the discontinuation group versus sixteen percent of those who continued, and for the harder secondary composite, which was essentially identical at around six and a half percent in each arm. Results held across the range of ejection fractions. The authors are candid that the primary endpoint was hospitalisation-heavy and behaved differently across the two trials, so this is not a mandate to stop, but it does give you defensible ground when a stable post-infarction patient with normal ventricular function wants to shed a medication. Running in the opposite direction, the New England Journal of Medicine published SINGLE-AF, a South Korean open-label trial of eighteen hundred patients with atrial fibrillation at intermediate stroke risk — a CHA2DS2-VASc score of one in men, two in women. Mean age was sixty. Over twenty-four months, the composite of stroke, systemic embolism, major bleeding or cardiovascular death occurred in four patients on a direct oral anticoagulant versus thirteen on none, roughly a two-thirds relative reduction, driven mainly by stroke. Major bleeding and serious adverse events looked similar between the groups. Event numbers are very small and the population was young and Korean, but for the class-two-A recommendation you have been discussing hesitantly with these patients, there is now randomised support for anticoagulating.

Still in cardiovascular risk, two trials tested delivery systems rather than drugs. In JAMA, Bhatt and colleagues reported ADHERE-ASCVD, a pragmatic trial embedded in Kaiser Permanente Northern California enrolling more than twenty thousand adults with established atherosclerotic disease or high risk who had recently stopped filling their statin. Patients were randomised to secure portal messaging, text messaging, non-secure email, or usual communication, and non-responders were re-randomised. Any digital outreach raised fourteen-day refill from about twelve percent to about fourteen percent — a modest two-percentage-point absolute gain, or roughly a twenty percent relative increase — and a second nudge to initial non-responders produced a similar further gain. Switching modality did nothing; repeating the same channel worked just as well. By twenty-eight days, about a quarter of the outreach group had refilled versus about a fifth with usual care. The honest reading is that most non-adherent patients stayed non-adherent, but at population scale a cheap, repeatable nudge moves the needle. JAMA Internal Medicine offers a sharper caution about the limits of process improvement. Leong and colleagues randomised nearly twenty-five hundred men with prostate cancer starting androgen deprivation therapy across fifty-five sites in eight countries to usual care or routine referral to an internist or cardiologist, who applied a protocol of a statin regardless of cholesterol plus a systolic target of one hundred thirty or lower. Over a median of nearly six years, the hierarchical composite favoured referral, but that win was almost entirely cholesterol: about a twelve milligram per decilitre difference in total cholesterol from mandated statin use. Closing systolic pressures were nearly identical, around one hundred thirty-one versus one hundred thirty-three, and there was no difference in cardiovascular death, infarction, stroke or heart failure. The practical lesson is that you probably do not need to refer these men out — you need to start the statin yourself.

Two further papers deal with pathways and guidelines that promise efficiency but did not deliver it. Also in The Lancet, PRESC1SE-MI, led by Boeddinghaus, was a stepped-wedge cluster-randomised trial across nineteen hospitals in ten countries, with more than sixty-seven thousand chest pain presentations, comparing the guideline-recommended zero-slash-one-hour high-sensitivity troponin pathway against the older zero-slash-three-hour approach. The faster pathway was non-inferior for the thirty-day composite of death or new type-one infarction, at just over one percent in each group. But median emergency department length of stay was identical — three hundred nine minutes in both arms. Faster troponin does not equal faster discharge when the rest of the department is the bottleneck. In PLOS Medicine, Chansamouth and colleagues ran a stepped-wedge trial in six hospitals in Laos comparing national antimicrobial prescribing guidelines delivered by smartphone application, with stewardship training, against the same guidelines on paper. Raw adherence looked higher with the app — about twenty-six percent versus seventeen percent for inpatient prescriptions — but after accounting for time and clustering, the prespecified improvement was not demonstrated, in inpatients or outpatients. Availability of a guideline, in whatever format, is not the constraint on prescribing behaviour.

Finally, a Viewpoint in The Lancet by Doyle and de Vries examines the thirteen systematic reviews published since 2017 on pubertal suppression and gender-affirming hormone therapy in adolescents, and argues that these reviews are being read as definitive verdicts on efficacy and safety when they were never designed to bear that weight. Their argument is a general one worth carrying beyond this topic: evidence-based medicine rests on empirical evidence, clinical expertise and patient values together, and a low certainty rating in a review reflects the limits of the available studies rather than proof of absent benefit.

If you only have time for one paper this week, make it the pooled beta blocker discontinuation analysis in The Lancet [1]. Almost every family physician carries a panel of stable post-infarction patients on a beta blocker nobody has questioned in years, and this is the largest randomised dataset telling you that stopping is a reasonable conversation.

Here are the key takeaways from this week in Family Medicine. In stable patients years after a myocardial infarction with preserved ejection fraction and no heart failure, beta blocker discontinuation was non-inferior to continuation over three years [1]. In atrial fibrillation with a CHA2DS2-VASc score of one in men or two in women, a direct oral anticoagulant reduced the composite of stroke, embolism, major bleeding and cardiovascular death, with no excess bleeding signal [2]. Repeated digital outreach modestly improves statin refills, and repeating the same channel works as well as switching [3]. For men starting androgen deprivation therapy, the benefit of specialist referral came from statin initiation, not from the referral itself, and no reduction in cardiovascular events was seen [4]. And two implementation trials remind us that a faster troponin protocol did not shorten emergency department stays [5], and moving guidelines onto a smartphone did not improve antibiotic prescribing [7].

That's your roundup for This Week in Family Medicine. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.