The edition · Top Clinical Updates
Catheter ablation for atrial fibrillation fails against a sham procedure
A double-blind sham-controlled trial finds no quality-of-life advantage for AF ablation, catheter-directed thrombolysis cuts early deterioration in intermediate-high-risk pulmonary embolism, and two weeks of ECG monitoring after syncope changes nothing.
The edition in brief
PVI-SHAM-AF randomised 262 patients with symptomatic atrial fibrillation to catheter ablation or a sham procedure, double-blind. Both groups improved substantially on the atrial fibrillation quality-of-life score; the difference between them was 2.6 points (95% CI -2.7 to 8.0, p=0.36). Ablation did not beat sham at six months. Much of what patients report after this procedure appears to be expectation, natural fluctuation and regression to the mean. PRAGUE-26 randomised 558 patients with intermediate-high-risk pulmonary embolism to catheter-directed alteplase plus anticoagulation or anticoagulation alone. The seven-day composite of death, recurrence or cardiorespiratory collapse fell from 6.8% to 0.7% (relative risk 0.10, 95% CI 0.02 to 0.44), driven by decompensation, with no excess bleeding — though two intracranial haemorrhages occurred in the thrombolysis arm and none in the control arm. An updated systematic review of 38 trials and 25,816 adults without diabetes puts placebo-subtracted weight loss at 14.8% for subcutaneous semaglutide, 19.0% for tirzepatide and 12.4% for oral orforglipron, with gastrointestinal side effects in three-quarters of patients and no new safety signals. ASPIRED randomised 2,234 patients with unexplained syncope to 14 days of ambulatory ECG monitoring or standard care and found no reduction in syncope episodes at one year. PRESC1SE-MI showed the 0/1 hour troponin pathway is as safe as 0/3 hours across 67,624 presentations but did not shorten emergency department stay by a single minute. Regulatory news is quiet. The American College of Physicians has issued a position paper on the ethics of artificial intelligence in practice. Today's pearl: intermediate-high-risk pulmonary embolism has a precise definition, and most of us apply it loosely.
AF ablation did not beat a sham procedure for quality of life
When a patient asks whether AF ablation will make them feel better, say that most people improve but a blinded trial could not show the procedure itself was the reason.
PRAGUE-26: catheter-directed thrombolysis cuts early collapse in intermediate-high-risk PE
In stable pulmonary embolism with right ventricular dysfunction and raised biomarkers, catheter-directed thrombolysis sharply reduces early deterioration — so identify these patients early and decide about intervention before they crash.
The current league table for weight loss drugs, with the side effects attached
Placebo-subtracted weight loss runs from about 6% with liraglutide to 19% with tirzepatide; expect gastrointestinal side effects in three-quarters of patients but discontinuation in only about one in ten.
Two weeks of ECG monitoring after unexplained syncope changed nothing
Two weeks of ambulatory ECG monitoring after unexplained syncope does not reduce further episodes — reserve it for patients with red flags rather than ordering it by default.
Intermediate-high-risk PE has a precise definition, and most of us apply it loosely
Classify every confirmed pulmonary embolism at diagnosis using all four criteria — stability, sPESI, right ventricular dysfunction and a raised biomarker — because a raised troponin alone is not intermediate-high risk.
The faster troponin pathway is safe, and it saved no time at all
Adopt the 0/1 hour troponin pathway because it is safe and gives an earlier answer — but not on the promise of faster emergency department throughput, which it does not deliver.
No new regulatory action today; the ACP sets out how to use AI ethically
Nothing new from the regulators today; if an AI tool informs a clinical decision, be able to disclose it, defend the reasoning yourself, and account for where the patient's data went.
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