This Week in Cardiology — Aug 31, 2026

Welcome to This Week in Cardiology. This week we're covering 10 notable papers spanning structural heart intervention, revascularization and imaging strategy in coronary disease, antithrombotic therapy after acute coronary syndromes, device-based rhythm management, and primary prevention in the very old. Almost all of it comes from the New England Journal of Medicine, with contributions from The Lancet and the European Heart Journal. Let's dive in.

We start with structural intervention, where a long-standing question about tricuspid regurgitation finally has a hard-outcome answer. In the New England Journal, Hausleiter and colleagues report TRIC-I-HF, which randomized 360 patients with symptomatic severe tricuspid regurgitation and an elevated risk of heart-failure events, two to one, to transcatheter tricuspid repair plus medical therapy or medical therapy alone [1]. This was an old and frail population — mean age just over 80, and more than half of the patients were women. The hierarchical composite of death, heart-failure hospitalization and quality-of-life gain at one year strongly favoured repair, with roughly two and a half wins for every loss. More importantly, the trial met its second primary endpoint: freedom from death or heart-failure hospitalization through three years was about 52 percent with repair versus about 21 percent with medical therapy, a reduction in the composite of roughly 60 percent. Major adverse events within 30 days occurred in about 6 percent of the patients who underwent repair. This moves tricuspid intervention beyond symptom relief and into the territory of event reduction, and it should change how you frame the conversation in the heart-team meeting.

Alongside that, Stähli and colleagues in the same journal tackled sequencing in patients who need both a valve and a stent [2]. In the TAVI PCI trial, 986 European patients with severe aortic stenosis and concomitant coronary disease were randomized to valve first or stent first. At one year, the composite of death, myocardial infarction, ischemia-driven revascularization, valve- or heart-failure-related rehospitalization, or major bleeding occurred in about 22 percent of the valve-first group and about 24 percent of the stent-first group — noninferior, with serious adverse events essentially balanced. The practical message is permissive: you can implant the valve first and deal with the coronaries afterwards without paying an outcome penalty, which is often easier logistically and haemodynamically.

Moving to coronary strategy, two trials this week pull in opposite directions on how hard we should look for ischemia. Biscaglia and colleagues, again in the New England Journal, ran AIR-STEMI, randomizing 1,823 patients with ST-elevation infarction and multivessel disease, after successful culprit treatment, to complete revascularization guided by functional coronary angiography — that is, angiography-derived physiology — versus conventional angiographic guidance [3]. Over a median follow-up of about 18 months, the composite of death, myocardial infarction, stroke or transient ischemic attack, or ischemia-driven revascularization occurred in roughly 9 percent of the physiology-guided group versus nearly 14 percent of the angiography-guided group, a relative reduction of just under 40 percent. Contrast-associated kidney injury and major bleeding were also lower with physiology guidance, at about 5 percent versus 7 percent. Fewer unnecessary stents, less contrast, better outcomes — that is an unusually clean result, and it argues for physiology-based lesion selection as the default for staged non-culprit work.

Contrast that with TARGET-CTCA, from Lee and colleagues, also in the New England Journal [5]. Here 3,170 patients across 14 United Kingdom emergency departments who had myocardial infarction ruled out, but who had a detectable troponin above 5 nanograms per litre marking intermediate risk, were randomized to outpatient computed tomographic coronary angiography-guided care or standard care. Uptake was excellent — over 90 percent of the imaging group actually had the scan. After a median of three years, myocardial infarction or cardiac death occurred in about 7 percent of patients in each group, with no difference. So a mildly elevated troponin in a patient whose infarction has been excluded identifies genuine risk, but routinely sending those patients for coronary computed tomography does not lower that risk. Reserve the scan for patients in whom you have a specific diagnostic question.

The antithrombotic theme is the busiest of the week, and it is largely a story of things that did not work. Gibson and colleagues report LIBREXIA ACS, a phase 3 trial of the oral factor XIa inhibitor milvexian at 25 milligrams twice daily added to standard antiplatelet therapy within seven days of an acute coronary syndrome [7]. More than 14,000 patients were enrolled before the trial was stopped for futility at interim analysis. Cardiovascular death, myocardial infarction or ischemic stroke occurred in about 5.4 percent on milvexian and 5.1 percent on placebo — no benefit. Intracranial or fatal bleeding was rare and identical in both arms, so the safety promise of factor XI inhibition held up, but efficacy in this setting did not.

Second, Omerovic and colleagues report SWITCH-SWEDEHEART, a registry-based, cluster-randomized, stepped-wedge trial in which seven Swedish regions switched their default P2Y12 inhibitor from ticagrelor to prasugrel across four periods, covering more than 17,000 unselected patients after percutaneous coronary intervention for acute coronary syndrome [8]. At one year, the composite of death, myocardial infarction or stroke occurred in about 11 percent under each policy, with no reduction in ischemic events under the prasugrel policy. Major bleeding was around 4 percent in both arms, with a modest edge favouring prasugrel. At a policy level, these two agents look interchangeable for ischemic protection — so choose on cost, tolerability and contraindications rather than on a presumed potency advantage.

Third, and most nuanced, Lee and colleagues report A-CLOSE, which enrolled 3,203 South Korean patients at high ischemic risk, twelve months after drug-eluting stent implantation, randomized to clopidogrel monotherapy or extended dual antiplatelet therapy with clopidogrel plus aspirin [9]. The primary net clinical endpoint at 24 months was essentially identical, around 5 percent in both arms, meeting noninferiority. But the components diverged sharply: death, myocardial infarction, stent thrombosis or stroke occurred in about 3.7 percent on monotherapy versus 1.6 percent on continued dual therapy — more than double — while moderate-to-severe bleeding fell from about 4 percent to under 2 percent with monotherapy. A neutral headline conceals a genuine trade-off, and in a truly high-ischemic-risk patient with low bleeding risk, dropping aspirin at one year is not a free move.

On the device and rhythm side, two trials challenge received wisdom in opposite directions. In The Lancet, Nielsen and colleagues report a national Danish double-blind trial of 1,001 patients undergoing biventricular pacing, randomized to left ventricular lead placement at the site of latest electrical activation versus conventional posterolateral non-apical placement [4]. Targeting achieved only about 9 milliseconds of extra electrical delay, and over a median follow-up of nearly four years, death or unplanned heart-failure hospitalization occurred in about 28 percent of the targeted group and 26 percent of the control group — no benefit, with more lead-related complications in the targeted arm and one procedure-related death. Electrically guided lead targeting, as implemented here, should not be routine.

Meanwhile, in the European Heart Journal, Boehmer and colleagues report ABLATE versus PACE, which randomized 196 patients aged 75 and older with symptomatic persistent atrial fibrillation and preserved ejection fraction — median age 82 — to pacemaker implantation with atrioventricular node ablation, or to pulmonary vein isolation [6]. At twelve months, the composite of hospitalization for atrial arrhythmia or heart failure, outpatient cardioversion, or upgrade to resynchronization occurred in about a quarter of the pace-and-ablate patients versus nearly half of the ablation patients, a reduction of roughly 55 percent. The events differed in kind: arrhythmia hospitalizations and cardioversions dominated in the pulmonary vein isolation arm, whereas heart-failure hospitalizations were more common after pacing and node ablation. Mortality, complications and quality of life did not differ. This is a small, open-label trial, but in the octogenarian with persistent fibrillation it legitimizes ablate-and-pace as a first-line strategy rather than a last resort.

Finally, prevention in the very old. Zoungas and colleagues report STAREE in the New England Journal, a placebo-controlled trial of atorvastatin 40 milligrams daily in 9,971 community-dwelling Australians aged 70 and over with no cardiovascular disease, diabetes or dementia [10]. Over a median of nearly six years, major cardiovascular events were reduced by about 30 percent. But the co-primary endpoint of disability-free survival — death, dementia or persistent physical disability — was not improved. Serious adverse events overall were equal at under 3 percent per group, though musculoskeletal, hepatobiliary and diabetes-related events were more common on atorvastatin. So statins do prevent heart attacks and strokes in healthy septuagenarians; they do not measurably extend independent living, and that is the honest framing for a shared decision.

If you only have time for one paper this week, make it TRIC-I-HF in the New England Journal [1]. It is the first randomized evidence that transcatheter tricuspid repair reduces death and heart-failure hospitalization rather than simply improving symptoms, and it should prompt you to reconsider referral thresholds for elderly patients with severe tricuspid regurgitation.

Here are the key takeaways from this week in Cardiology. Transcatheter tricuspid repair now has hard-outcome evidence in symptomatic severe regurgitation, and valve-first sequencing before percutaneous coronary intervention is a legitimate default in patients with both aortic stenosis and coronary disease. Physiology-guided complete revascularization after ST-elevation infarction beat angiographic guidance on both efficacy and safety, while routine coronary computed tomography in ruled-out chest pain with mildly raised troponin changed nothing over three years. In antithrombotics, milvexian added nothing after acute coronary syndrome, prasugrel and ticagrelor policies performed alike in Sweden, and dropping aspirin at one year in high-ischemic-risk stented patients trades fewer bleeds for more ischemic events. Electrically targeted left ventricular lead placement did not improve resynchronization outcomes, whereas pace-and-ablate outperformed pulmonary vein isolation in octogenarians with persistent atrial fibrillation. And atorvastatin in healthy over-seventies cut cardiovascular events by about 30 percent without extending disability-free survival.

That's your roundup for This Week in Cardiology. 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.