THE ROUNDS REPORT
ACC.26 landed in New Orleans this quarter, and the cardiology data came out swinging. In directions nobody expected.
Aspirin after a stent… standard of care, right? Maybe not.
Impella in elective high-risk PCI. The long-awaited evidence finally arrived. The verdict may not be what you expect. And first-line ablation for persistent AF just leapfrogged a decade of antiarrhythmic drug cycling.
But the most surprising finding this quarter has nothing to do with cardiology. A sepsis triage tool that doesn't change antibiotic timing somehow cut mortality by three percentage points.
Finally, IPF patients have something to add to their antifibrotic regimen.
Let's get to it.
THE BIG FIVE GAME-CHANGERS
1. AVANT GUARD: First-Line Ablation Beats Antiarrhythmic Drugs in Persistent AF
Pulsed-field ablation has been used after antiarrhythmic failure for years. AVANT GUARD just moved it to the front of the line.
310 patients with previously untreated persistent AF were randomized at 68 sites across 14 countries to first-line PFA or antiarrhythmic drug therapy, with all patients receiving an insertable cardiac monitor. At 12 months, treatment success was 56% with PFA versus 30% with antiarrhythmics — HR for treatment failure 0.46 (95% CI 0.33–0.65; P<0.001). Procedure-related serious adverse events settled at 5.1%, comfortably below the 12% performance goal.
Practice implication: For symptomatic persistent AF patients who are highly motivated to avoid long-term drug therapy, first-line PFA referral is now defensible without requiring prior antiarrhythmic failure. Physicians may want to consider accelerating referrals for highly symptomatic patients. One important note: the trial was temporarily paused in late 2024 after six early neurological events in the PFA arm. It resumed successfully with stricter safety guardrails — excluding patients with CHA₂DS₂-VASc ≥4, mandating pre-procedural left atrial thrombus screening, and enforcing a target ACT of 350 seconds. Expect updated AF guidelines within 12 months. Trial was industry-sponsored by Boston Scientific.
2. HOST-EXAM 10-Year: Clopidogrel Should Be the Default After PCI, Not Aspirin
The original HOST-EXAM trial at 2 years already favored clopidogrel. A decade of follow-up makes the case decisively.
5,438 Korean adults who were event-free 6–18 months after DES PCI were randomized to clopidogrel 75 mg or aspirin 100 mg daily. At a median 10.5 years of follow-up, the primary net clinical composite favored clopidogrel at 25.4% versus 28.5% with aspirin (HR 0.86; 95% CI 0.77–0.96; P=0.005). Both non-fatal thrombotic and bleeding outcomes favored clopidogrel, though all-cause mortality remained statistically similar between the two arms (13.4% vs 12.5%).
Practice implication: For patients who have completed their DAPT window without events, clopidogrel monotherapy is now the evidence-based default over aspirin — particularly in those with prior GI bleeding or high bleeding risk. Physicians should note this is an exclusively Korean cohort, and CYP2C19 loss-of-function carriers may warrant individualized decisions.
3. CHIP-BCIS3: Impella in High-Risk Elective PCI Doesn't Help and May Harm
Prophylactic mechanical circulatory support for complex elective PCI has been a widespread practice looking for evidence. CHIP-BCIS3 is that evidence.
300 UK patients with severe LV dysfunction (median LVEF 27%) and complex multivessel CAD were randomized to Impella CP support versus standard care during elective PCI. The primary hierarchical win-ratio composite of death, stroke, MI, and CV hospitalization favored standard care (win ratio 0.85; standard care won 43% of pairwise clinical outcomes versus 36% for Impella). All-cause mortality was numerically higher with Impella. Major vascular complications were substantially more frequent in the Impella arm.
Practice implication: Routine prophylactic Impella for elective high-risk PCI has no mortality benefit and increases procedural harm. For internists co-managing these patients, this is the data to anchor a conversation when device support is proposed in a non-shocked patient.
4. TETON-1: Inhaled Treprostinil Slows Lung Function Decline in IPF
IPF has two approved antifibrotics. For the first time, a third agent added on top of them actually works.
598 patients with IPF — approximately 75% already on nintedanib or pirfenidone — were randomized to nebulized treprostinil or placebo for 52 weeks. Mean FVC change at week 52: −43.3 mL with treprostinil versus −196.2 mL with placebo — a between-group difference of 130.1 mL (95% CI 82.2–178.1; P<0.001). Time to clinical worsening: HR 0.67 (95% CI 0.52–0.88; P=0.003), a 33% risk reduction. Cough was more common with treprostinil (54.8% vs 33.1%).
Practice implication: Inhaled treprostinil is the first add-on therapy to demonstrate disease-modifying efficacy in IPF on top of existing antifibrotics. IPF patients with progressive disease on nintedanib or pirfenidone may benefit from early pulmonology referral ahead of anticipated FDA label expansion later this year. Trial was industry-sponsored by United Therapeutics.
5. PRONTO: A Procalcitonin-Guided Algorithm Cuts Sepsis Mortality Without Delaying Antibiotics
Adding a rapid procalcitonin result to the NEWS2 score already used in emergency departments just produced one of the more surprising sepsis findings in years — not by changing antibiotic timing, but by improving outcomes anyway.
7,667 adults with suspected sepsis across 20 hospital emergency departments in England and Wales were randomized to procalcitonin-guided management plus NEWS2 versus NEWS2-based usual care. IV antibiotic initiation at 3 hours was identical between groups (48.4% vs 48.2%; P=0.95). 28-day mortality: 13.6% versus 16.6% — an adjusted absolute risk difference of −3.12 percentage points (90% CI −4.68 to −1.57; P=0.0009), representing a 17% relative risk reduction.
Practice implication: A pragmatic, widely deployable triage tool was associated with a meaningful absolute mortality reduction in suspected sepsis without changing antibiotic speed or volume. The benefit likely reflects better overall escalation decisions rather than antibiotic stewardship alone. Physicians may want to consider how their institution's sepsis triage protocols incorporate biomarker-guided risk stratification alongside clinical scoring tools. Trial was NIHR-funded with no industry conflict.
CLINICAL PEARLS THAT MATTER
Iliac-Vein Stenting Reduces Post-Thrombotic Syndrome Severity — C-TRACT (NHLBI-funded RCT) showed endovascular therapy plus standard care reduced Venous Clinical Severity Score by an adjusted 2.0 points (P=0.001) and improved VEINES-QOL by 14.5 points (P<0.001) versus standard care alone in adults with moderate-to-severe PTS and iliac obstruction after prior DVT; higher bleeding rates were observed in the endovascular arm. PTS affects roughly 25–30% of proximal DVT patients — those with persistent swelling, venous claudication, or ulceration may warrant referral for venous imaging and specialist evaluation. C-TRACT - NEJM
CRISPR Base Editing of PCSK9: One Infusion, Durable LDL Reduction — VERVE-102 Phase 1b showed a single IV infusion of a lipid-nanoparticle-delivered adenine base editor produced dose-dependent durable reductions in PCSK9 (51–88% across doses) and LDL-cholesterol (up to 62%, absolute 78 mg/dL at the highest dose) in HeFH and premature ASCVD patients on maximal lipid-lowering therapy, with no dose-limiting toxicities. Phase 1b data only — cardiovascular outcomes years away — but this is the first clinical proof that in-vivo CRISPR gene editing can permanently modify a metabolic target in humans. VERVE-102 - NEJM
Mechanical Thrombectomy Extends to Medium-Vessel Occlusion Stroke — RCT (564 patients, 48 centers in China, within 24 hours of onset, NIHSS ≥6) showed endovascular thrombectomy plus medical therapy achieved functional independence (mRS 0–2) at 90 days in 58.6% of patients versus 46.6% with medical therapy alone (adjusted rate ratio 1.24; 95% CI 1.07–1.44; P=0.004), with higher symptomatic intracranial hemorrhage in the thrombectomy arm (4.7% vs 2.2%). For hospitalists receiving stroke patients, "distal occlusion" no longer automatically means "thrombectomy not indicated." MVO Thrombectomy Trial - NEJM
GLP-1 Therapies Carry a Meaningful Muscle-Loss Burden — Systematic review of 36 RCTs (Batsis et al., Annals of Internal Medicine) found a median 34.9% (IQR 19.0–48.2%) of total weight loss on incretin-based therapy came from muscle-related tissue; 68% of studies exceeded pre-specified muscle-loss benchmarks. Physicians may want to consider discussing muscle preservation strategies with patients initiating GLP-1 therapy, particularly in older adults where sarcopenic-obesity outcomes are worse. Batsis et al. - Annals of Internal Medicine
MONDAY MORNING ROUNDS: 5 KEY DISCUSSION POINTS
First-line PFA beat antiarrhythmic drugs in persistent AF (56% vs 30% treatment success at 12 months; HR 0.46; P<0.001) — but note the trial's temporary pause due to early neurological events and the stricter patient selection criteria now required.
Clopidogrel outperformed aspirin at 10 years post-PCI on the net clinical composite (HR 0.86; P=0.005), driven by non-fatal thrombotic and bleeding events — all-cause mortality was not significantly different between groups.
Impella in elective high-risk PCI produced no benefit and numerically higher mortality (win ratio 0.85; standard care won 43% of pairwise outcomes vs 36% for Impella) — prophylactic mechanical support in non-shocked patients lacks justification.
Inhaled treprostinil slowed FVC decline by 130.1 mL at 52 weeks (P<0.001) and reduced clinical worsening by 33% (HR 0.67) in IPF patients already on antifibrotic therapy — the first effective add-on strategy for progressive IPF.
Procalcitonin-guided sepsis triage cut 28-day mortality by 3.12 percentage points (13.6% vs 16.6%; 17% relative risk reduction; P=0.0009) across 7,667 patients without changing antibiotic timing.
ESSENTIAL READING
Cardiology
Pulmonology
Infectious Disease / Hospital Medicine
Hematology / Vascular
Neurology
Endocrinology
Cardiology / Genetics
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