The edition · Top Clinical Updates
Catheter ablation for atrial fibrillation did not beat a sham procedure on quality of life
A double-blind, sham-controlled trial puts a number on how much of ablation's symptom benefit is the procedure itself; plus a tobacco treatment guideline that ranks the drugs, and evidence that imported risk equations misjudge age.
The edition in brief
PVI-SHAM-AF randomised 262 patients with symptomatic atrial fibrillation 2:1 to catheter ablation or a sham procedure, double-blind, at nine sites in Germany and Poland. Both groups improved substantially on the AFEQT quality-of-life score — from 61.3 to 81.1 after ablation and from 59.2 to 74.9 after sham. The between-group difference was 2.6 points (95% CI -2.7 to 8.0, p = 0.36). Ablation was not superior. The trial did not test rhythm outcomes or stroke, and recruitment was difficult: 1,199 patients were approached and 262 consented. The 2026 VA/DoD tobacco use treatment guideline makes 32 recommendations across 10 topic areas. The strong ones are usable anywhere: motivational interviewing to engage people in treatment, FDA-approved pharmacotherapy, varenicline over other single agents, and combination nicotine replacement — patch plus lozenge — over a single agent. Varenicline is also strongly recommended for smokeless tobacco. For people not ready to quit within 30 days, offering nicotine replacement or varenicline anyway is a weak recommendation. A BMJ cohort study built matched five-year cardiovascular risk equations in 47,958 New Zealand and 46,558 Chinese adults with diabetes. Most predictor effects matched, but age did not: hazard ratio 1.61 per decade in New Zealand women against 2.51 in Chinese women. Recalibrating the imported equation did not fix it; replacing the age coefficient did. THESUS-HF II followed 1,578 adults with acute heart failure across 50 hospitals in 17 African countries. Median age was 56. In-hospital mortality was 8.7% and 180-day mortality 20.6%, with target drug doses reached in fewer than half.
A tobacco treatment guideline that says which drug, not just that you should treat
Lead with varenicline, use combination nicotine replacement rather than a patch alone, and offer treatment even to people who say they are not ready to quit.
Imported cardiovascular risk equations get age wrong, and recalibration does not fix it
Treat cardiovascular risk percentages from imported equations with caution in non-Western populations, particularly at the extremes of age.
Acute heart failure across 17 African countries: median age 56, 180-day mortality 20.6%
Getting heart failure drugs started is no longer the bottleneck; uptitration and follow-up are, and both need to be arranged before the patient leaves.
"Do you smoke?" misses most tobacco use in India
Ask about tobacco in any form, including chewed and applied products, and look inside the mouth of anyone who says yes.
Ablation for atrial fibrillation did not beat sham on symptoms
Tell patients considering ablation purely for symptoms that a double-blind sham-controlled trial found no significant quality-of-life advantage at six months.
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