This Week in Cardiology — Sep 7, 2026

Welcome to This Week in Cardiology. This week we're covering 10 notable papers spanning revascularisation — from the operating theatre to the cath lab — heart failure and decongestion, and risk stratification across arrhythmia, valve disease and occupational cardiology. Let's dive in.

We start with revascularisation, and a long-awaited answer from JAMA Cardiology. Taggart and colleagues report the 15-year extended follow-up of the Arterial Revascularization Trial, in which just over three thousand patients undergoing bypass surgery at 28 centres in seven countries were randomised to bilateral versus single internal thoracic artery grafting [1]. Vital status was known for 98 percent of patients at 15 years, and the answer is flatly neutral: about 38 percent of patients died in each arm, with no separation whatsoever in the survival curves, and no difference in the composite of death, myocardial infarction or stroke. Before you conclude the multiple arterial graft hypothesis is dead, note the contamination the authors themselves emphasise: roughly one in seven patients assigned to bilateral grafting received only a single arterial graft, and close to a quarter OF PATIENTS in the single-graft arm received a radial artery anyway. So this is an intention-to-treat result in a trial with substantial crossover, and the honest reading is that the hypothesis remains untested rather than refuted. For the practising cardiologist referring patients for surgery, there is no trial-level mandate to insist on bilateral grafting, and the operative decision remains one of surgeon experience and patient risk — particularly sternal wound risk in diabetes and obesity.

Moving from the surgical to the percutaneous, two papers this week address intracoronary imaging and they fit together neatly. In the European Heart Journal, Bulluck and colleagues pooled 17 randomised trials and just over 14,000 patients comparing intravascular ultrasound guidance with angiography guidance for drug-eluting stent implantation [2]. Overall, imaging guidance cut cardiac death by roughly 30 percent — but the pre-specified geographic interaction is the story. In the ten East Asian trials, cardiac death was reduced by about 44 percent; in the seven non-Asian trials, there was no benefit at all, with a point estimate that actually favoured angiography guidance. The same divergence appeared for target-vessel infarction, target-vessel revascularisation and major adverse events. The one consistent finding across geographies was a reduction in definite stent thrombosis, cut by roughly 60 percent. The authors suspect the difference lies not in the imaging catheter but in what operators do with the information — how aggressively they optimise stent expansion and apposition. That interpretation is reinforced by a Nature Reviews Cardiology review from Biccirè and colleagues, which walks through the eight large randomised imaging trials and argues that heterogeneity in populations, in imaging protocols, and in the absence of standardised optimisation criteria explains much of the mixed signal [3]. The practical message from both: intracoronary imaging is not a talisman. If you are going to use it, you need a defined protocol for what constitutes an acceptable result and a willingness to post-dilate accordingly, and you should be targeting complex lesions where the yield is highest.

Staying with acute coronary care, Heart publishes a retrospective registry cohort from a regional emergency network on where to take the patient after out-of-hospital cardiac arrest [4]. Among 613 adults with return of spontaneous circulation and ST-elevation on the post-arrest electrocardiogram, Hunt and colleagues compared direct transfer to a primary PCI centre against indirect transfer via a non-PCI hospital. Call-to-balloon time was around 88 minutes shorter with direct transfer, and survival to discharge was 81 percent versus 68 percent. After adjustment, indirect transfer roughly doubled to tripled mortality at 30 days, and by three years the cumulative death rate was about 28 percent with direct transfer versus 41 percent — an absolute difference of about 13 percentage points. Critically, the excess risk was front-loaded and stabilised by around six months, meaning the long-term advantage is bought entirely in the first days. This is observational and subject to selection bias, but it aligns with existing evidence and supports pre-hospital triage protocols that bypass the local hospital for these patients.

Turning to heart failure, the European Journal of Heart Failure carries an individual patient data pooling of the three recent decongestion trials — ADVOR with acetazolamide, CLOROTIC with hydrochlorothiazide, and PUSH-AHF with natriuresis-guided therapy — totalling just over a thousand patients with a mean age of 79 [5]. Intensified decongestion clearly did what it was designed to do: significantly more diuresis and natriuresis at 24 and 48 hours, no excess creatinine doubling at day three, and length of stay shortened by about a day. But the primary endpoint, 90-day heart failure re-hospitalisation or death, was flatly neutral. There was a signal towards lower in-hospital mortality, roughly halved, which the authors explicitly label exploratory and hypothesis-generating — treat it as such. The take-home is that better decongestion is a worthwhile in-hospital goal for symptoms and length of stay, but it does not by itself buy post-discharge event reduction. That still comes from guideline-directed medical therapy, and a second paper in the same journal shows how far we have to go there. Ferrannini and colleagues analysed over 54,000 patients in the Swedish Heart Failure Registry stratified by chronic kidney disease and type 2 diabetes [6]. About a quarter OF PATIENTS had kidney disease alone and roughly one in nine had both conditions, with kidney disease most prevalent in preserved ejection fraction. Event rates climbed stepwise from neither condition, to diabetes alone, to kidney disease alone, to both — and kidney disease contributed more risk in reduced ejection fraction than in preserved. For end-stage renal disease, diabetes alone added nothing independently, kidney disease alone tripled the risk, and the combination raised it six-fold. Yet heart failure medication use, particularly mineralocorticoid receptor antagonists, was lowest precisely in the kidney disease groups. That is therapeutic inertia in the patients with the most to gain.

Three papers this week refine risk stratification. In the European Heart Journal, a Finnish nationwide registry linked to more than half a million digitally recorded electrocardiograms categorised nearly 41,000 patients as atrial fibrillation only, atrial flutter only, or both [7]. Patients with flutter alone had about a 40 percent lower adjusted rate of ischaemic stroke than those with fibrillation alone, while patients with both arrhythmias had a slightly higher rate. The finding held in periods off anticoagulation, before ablation, and across risk score categories. This does not license withholding anticoagulation in flutter — most flutter patients eventually develop fibrillation, and the combined group did worse — but it does suggest the two rhythms are not thromboembolically identical. Also in the European Heart Journal, the TARGET-D trial tested whether targeted, algorithm-titrated vitamin D3 dosing aimed at a 25-hydroxyvitamin D level above 40 could reduce events after myocardial infarction [8]. Among 630 patients followed just over four years, the primary composite was not significantly reduced — about 16 percent versus 18 percent. A nominally lower recurrent infarction rate in the treatment arm is a secondary endpoint in a neutral trial and should not change practice. Vitamin D remains a bystander, not a target. Finally, from the European Journal of Heart Failure, a systematic review of eleven observational studies comparing TAVI outcomes in isolated aortic stenosis versus stenosis with concomitant transthyretin amyloidosis found similar low 30-day mortality in both, but more acute kidney injury and more permanent pacemakers peri-procedurally, and higher heart failure readmissions and late mortality in the amyloid group [9]. Amyloidosis should not exclude a patient from valve replacement — it should change how closely you follow them afterwards, and it should prompt disease-specific therapy. And rounding out the week, the American College of Cardiology and American Heart Association released a joint scientific statement on the tactical athlete — firefighters, law enforcement, and military personnel — with eleven sections and clinical considerations tables covering everything from preparticipation evaluation and genetic cardiomyopathies to channelopathies and the older tactical athlete [10]. If you sign return-to-duty forms, this is a reference document worth bookmarking.

If you only have time for one paper this week, make it the geographic heterogeneity meta-analysis of intravascular ultrasound-guided PCI in the European Heart Journal [2]. It reframes a question many of us thought was settled and suggests that the benefit of imaging depends on operator behaviour rather than on the imaging itself.

Here are the key takeaways from this week in Cardiology. At 15 years, bilateral internal thoracic artery grafting shows no survival advantage over single grafting by intention to treat, though crossover was substantial enough that the question is not fully closed. Intracoronary imaging reduces stent thrombosis everywhere, but its broader benefit has been seen mainly in East Asian trials — use it with a defined optimisation protocol, not as a reflex. After cardiac arrest with ST-elevation, take the patient directly to a primary PCI centre; the survival gain is earned in the first thirty days and persists to three years. Intensified decongestion in acute heart failure improves diuresis and shortens stay but does not reduce 90-day death or readmission. And in heart failure with chronic kidney disease, mineralocorticoid receptor antagonist use is lowest in exactly the patients at highest risk.

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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