The Western AF meeting, aspirin, cannabis use, LVEF in athletes, and shared decision making before ICD implantation are the topics John Mandrola, MD, discusses in this week’s podcast.
https://www.medscape.com/viewarticle/...

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In This Week’s Podcast
For the week ending March 1, 2024, John Mandrola, MD, comments on the following news and features stories: aspirin, cannabis use, left ventricular ejection fraction (LVEF) in athletes, and shared decision making (SDM) before implantable cardioverter defibrillator (ICD) implantation.

Western AF Meeting
Before I start, I want to say a few words about the Western AF congress in Park City Utah last weekend. First, thank you to my friend Nassir Marrouche for the invitation to this incredible meeting. It’s a remarkable 2 days of lectures on atrial fibrillation (AF)

I had two assignments. One was to be on a panel discussing the topic, “Every patient with AF deserves a PVI.” It’s an obviously provocative topic. There was a spirited discussion about doing pulmonary vein isolation (PVI) and how early is better than later.

One of the main comments I made was to say that back in the early days (20 years ago) when I was learning AF ablation, I set a Google alert for the term “AF ablation.” I did this to pick up tips and tricks. And in those days, it worked. All of us were learning.

But. In recent years, these alerts mostly point me to business stories on how big the AF ablation market is and is going to be. It’s especially crazy these weeks and months because all the big industry players are marketing their new way to kill atrial myocytes with pulsed field ablation (PFA). The marketing with PFA rivals that of left atrial appendage closure.

My thinking, though, is that a sign of being more advanced as a field would be if we did fewer PVIs. That would mean we’d have done something to stop the massive increase in AF incidence. For example, if we learned more about the upstream causes of AF, we likely would need fewer PVIs.

I tried to remind my electrophysiology (EP) friends that while the PVs are easy to isolate, we don’t really know why we do it. Sure, in some cases of focal AF there is a driver in the PVs. But that’s rare.

Just before our session, Eric Prystowsky showed the famous cartoon of the person looking for his car keys in the dark. Where was he looking? Under the light post. Because that was the only place he could see.

That image is what got me thinking about how little our knowledge base has advanced since we started doing PVI. Anyway, you all will be seeing lots of news stories on AF ablation because of PFA.

I am not sold on it yet. The first-generation catheters are rudimentary. Maybe in a few years, the delivery system will be improved and we can adopt it. But still, PFA is just another way to burn myocytes. It doesn’t advance our knowledge base.

I am afraid that by exciting the field about doing more PVI, it may slow our knowledge about AF even more than it already is.

Aspirin Is Back in the News
I like talking about aspirin (ASA) because a) there are a bunch of trials to interpret, b) it’s directly relevant for cardiac prevention, and c) it’s not entirely clear how to translate the trial data.

The most recent data is now 5 years old. In 2018, which seems like yesterday, there were three primary prevention trials published: ARRIVE (patient with elevated atherosclerotic cardiovascular disease risk), ASCEND (diabetic patients) and ASPREE (older patients). The take-home from these 3 trials was that there was no net benefit to primary prevention ASA. The small reductions in non-fatal events were countered by an increase in major bleeding.

But. (Yes, there is always a but.) Most of these patients were not taking ASA at the time of trial enrollment. So, these were essentially studies of starting ASA.

But that’s not the main scenario I see in the office. In the office I mainly see patients who are taking ASA and the question of deprescribing comes up. To be honest, I’ve been recommending stopping the ASA, especially when patients are on an oral anticoagulant (OAC).

Transcript in its entirety can be found by clicking here:
https://www.medscape.com/viewarticle/...