THE ROUNDS REPORT
This summer, Spider-Man is slinging webs once again and we're back slinging the best of clinical research from the last quarter.
First: aspirin, the $4 bottle on every pharmacy shelf, just went head-to-head with a DOAC after joint replacement surgery. The result was a stunning tie and a reason to rethink VTE prophylaxis for millions of patients.
Then: finerenone, already proven in diabetic kidney disease, crossed the aisle to non-diabetic CKD. A drug finding its footing in new territory — 24 countries, 1,584 patients, and a meaningful slowdown in eGFR decline.
And then there's the comeback story nobody saw coming: an antibiotic from the 1980s, largely forgotten for decades, just beat carbapenems head-to-head for drug-resistant bloodstream infections. Sometimes the old heroes are the ones worth rooting for.
Plus: tirzepatide makes a compelling case for going big early in type 2 diabetes. And extended DAPT in multivessel disease will spark arguments in every cardiology conference room for the foreseeable future.
Here's what you need to know.
THE BIG FIVE GAME-CHANGERS
1. EPCAT III: Aspirin Alone Matches Rivaroxaban-Then-Aspirin After Joint Replacement Orthopedics / Hospital Medicine
Post-arthroplasty VTE prophylaxis has been notoriously variable — DOACs, LMWH, warfarin, aspirin, and every combination in between. EPCAT III just provided the clearest head-to-head data yet.
Adults undergoing total hip or knee arthroplasty were randomized to aspirin alone (n=2,718) or a 5-day course of rivaroxaban 10 mg followed by aspirin (n=2,647), with aspirin then continued for 9 days post-knee and 30 days post-hip. Symptomatic VTE: 0.48% with aspirin alone versus 0.45% with rivaroxaban-then-aspirin; risk difference 0.02 pp (95% CI −0.34 to 0.39; P<0.001 for noninferiority; margin 0.7 pp). No clinically relevant bleeding difference between arms.
Practice implication: For elective hip or knee arthroplasty patients without a separate anticoagulation indication, physicians may want to consider aspirin monotherapy as a simpler, lower-cost prophylaxis strategy. Physicians should note that patients at elevated VTE risk or already on anticoagulation may warrant individualized assessment.
2. DAPT-MVD: Extended Dual Antiplatelet Therapy Cuts Events in Multivessel CAD Cardiology
The prevailing tide in post-PCI care has run toward shorter DAPT. DAPT-MVD pushes back, at least in a specific, well-defined population.
8,250 patients with multivessel CAD, event-free 12 months after a drug-eluting stent, were randomized at 97 Chinese centers to an additional 12 months of clopidogrel plus aspirin or aspirin alone (median follow-up 34.3 months). Primary composite of CV death, nonfatal MI, or nonfatal stroke: 5.8% versus 6.8%; HR 0.82 (95% CI 0.69–0.98; P=0.03). Clinically relevant bleeding: 1.4% versus 1.5%; HR 0.89 (95% CI 0.61–1.30; P=0.54), no significant increase.
Practice implication: Physicians managing stable post-PCI patients with multivessel disease may want to consider the DAPT-MVD profile when weighing extended DAPT decisions, though the trial's young East Asian cohort and exclusive use of clopidogrel limit direct generalizability to older Western patients or those on potent P2Y12 inhibitors.
3. FIND-CKD: Finerenone Now Has Evidence in Non-Diabetic CKD Nephrology
Finerenone has been firmly established in diabetic kidney disease. FIND-CKD extends the evidence to a far larger population — adults with CKD who don't have diabetes.
1,584 adults with non-diabetic CKD on maximally tolerated RAS blockade (baseline mean eGFR 46.7 mL/min/1.73 m²; median UACR 818.9 mg/g) across 24 countries were randomized to finerenone 10/20 mg daily or placebo. Primary outcome (total eGFR slope over 32 months): finerenone reduced the rate of kidney function decline by 0.7 mL/min/1.73 m²/year (95% CI 0.3–1.1; P<0.001). Key secondary cardiorenal composite: HR 0.77 (95% CI 0.60–0.99; P=0.043). The most common CKD etiologies were chronic glomerulonephritis (57%) and IgA nephropathy (26%).
Practice implication: Physicians managing progressive non-diabetic CKD already on maximal RAS blockade may want to consider finerenone as an additional option, with close monitoring of serum potassium. The eGFR slope benefit is modest and dedicated cardiovascular outcomes data in this population are still awaited.
4. ASTARTÉ: A Forgotten Antibiotic Spares Carbapenems for Drug-Resistant Bacteremia Infectious Disease
Temocillin — a narrow-spectrum beta-lactam largely shelved since the 1980s — just made one of the more surprising comebacks in recent infectious disease literature.
334 patients with bacteremia from third-generation cephalosporin-resistant Enterobacterales across 29 Spanish hospitals were randomized to IV temocillin 2 g every 8 hours or a carbapenem (meropenem or ertapenem). Clinical success rates were comparable within the prespecified noninferiority margin. Probability of a better DOOR outcome with temocillin: 50.4%, effectively identical to carbapenem.
Practice implication: Physicians and antimicrobial stewardship teams at institutions where temocillin is available may want to consider it as a carbapenem-sparing option for ESBL and AmpC bloodstream infections after source control. Where temocillin is not on formulary, this trial may be worth bringing to pharmacy and therapeutics committees.
5. SURPASS-EARLY: Tirzepatide Outperforms Conventional Intensification in Early Type 2 Diabetes Endocrinology
The conventional approach to type 2 diabetes is stepwise: start simple, intensify as needed. SURPASS-EARLY tests whether going bigger earlier with tirzepatide produces better outcomes from the start.
794 adults with type 2 diabetes diagnosed within the past 4 years (A1c 7–9.5%; ~85% treatment-naïve; 78 sites in 10 countries) were randomized to tirzepatide 15 mg or intensified conventional care (including non-tirzepatide GLP-1 RAs) for 2 years. A1c reduction: −1.99 pp versus −1.32 pp; treatment difference −0.68 pp (95% CI −0.84 to −0.51; P<0.001). Weight difference: −8.0 kg (95% CI −9.39 to −6.50; P<0.001). Normoglycemia (A1c <5.7%) achieved in 60.2% versus 24.0% of patients.
Practice implication: For recently diagnosed type 2 diabetes with overweight or obesity where access and cost allow, physicians may want to consider earlier tirzepatide as a discussion point with patients, particularly given the 60% normoglycemia rate. The open-label design and industry funding warrant the usual interpretive caution.
CLINICAL PEARLS THAT MATTER
Bilateral Focused Ultrasound for Parkinson's: Compelling Unilateral Results, Concerning Bilateral Tradeoffs (Neurology) — Single-arm trial of staged bilateral MRgFUS pallidothalamic tractotomy (54 patients treated unilaterally; 40 proceeded to staged bilateral treatment across 9 international centers) showed ~50% MDS-UPDRS Part III OFF-score improvement with unilateral treatment. Adding the second side produced only modest additional motor gain while raising persistent moderate-to-severe speech, gait, and balance adverse events from ~2% to ~25%. Physicians managing Parkinson's patients referred for ablative procedures may want to counsel patients carefully about cumulative bilateral risk. Lancet Neurology
Carvedilol Outperforms Other Beta-Blockers in Cirrhosis (Hepatology) — Target-trial emulation of 26,128 US adults with cirrhosis found carvedilol associated with 17–20% lower major decompensation and 20–34% lower variceal-hemorrhage risk versus nadolol or propranolol. Physicians managing cirrhotic patients on nonselective beta-blockers may want to consider carvedilol as the preferred agent, consistent with Baveno guidelines. Annals of Internal Medicine
IL-10 Autoantibodies Identify a Distinct IBD Subtype (Gastroenterology / Immunology) — Neutralizing anti-IL-10 autoantibodies were found in 3.5% (173/4,909) of IBD patients versus 0% of controls (P<0.001), strongly linked to HLA-DRB1*01:03 (OR up to 50.0; 95% CI 16.4–152.3). A discovery/biomarker study — not yet interventional — but one that may reframe how physicians think about refractory IBD and future biologic strategies. NEJM
Mild Sleep Restriction Causes Weight Gain Through Inactivity, Not Overeating (Preventive Medicine) — Pooled analysis of 2 randomized crossover trials (95 adults, 6 weeks of ~80 minutes/night sleep restriction) found weight increased ~0.5 kg and waist circumference ~0.5 cm, driven by reduced physical activity (+17 min sedentary/day), not increased caloric intake. Leptin actually rose. Physicians counseling patients on cardiometabolic risk may want to incorporate sleep-duration targets alongside diet and exercise. Annals of Internal Medicine
MONDAY MORNING ROUNDS: 5 KEY DISCUSSION POINTS
Aspirin alone matched rivaroxaban-then-aspirin for VTE prevention after hip/knee arthroplasty (0.48% vs 0.45%; P<0.001 for noninferiority) with no clinically relevant bleeding difference, supporting a simpler prophylaxis strategy in appropriate patients.
Extended DAPT cut the 36-month MACE composite by 18% (5.8% vs 6.8%; HR 0.82; P=0.03) in multivessel CAD patients event-free at 12 months post-DES, without increasing clinically relevant bleeding, though the young East Asian clopidogrel-only cohort limits generalizability.
Finerenone slowed eGFR decline by 0.7 mL/min/1.73 m²/year (P<0.001) in 1,584 non-diabetic CKD patients on maximal RAS blockade, extending the nonsteroidal MRA class beyond diabetic kidney disease for the first time.
Temocillin was noninferior to carbapenems (DOOR probability 50.4%) for third-generation cephalosporin-resistant Enterobacterales bacteremia, a meaningful antimicrobial stewardship option where the drug is available.
Tirzepatide returned 60.2% of early-diagnosed type 2 diabetics to normoglycemia versus 24.0% with intensified conventional care (A1c difference −0.68 pp; weight difference −8.0 kg; P<0.001 for both) over 2 years.
The content provided in The Rounds Report is for educational and informational purposes only and does not constitute medical advice, diagnosis, treatment recommendations, or professional medical guidance. This newsletter presents summaries and analysis of published medical research and should not be used as a substitute for professional medical judgment, clinical decision-making, or consultation with qualified healthcare providers. Always consult with appropriate medical professionals and refer to original research sources before making any clinical decisions. The Rounds Report does not establish a doctor-patient relationship and readers should not rely on this content for patient care decisions.
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