Name: Feb 13 2026 This Week in Cardiology
Uploaded: 2026-02-19T22:09:57.000Z
Duration: 29 min 40 s
Description: Thousands of YouTube videos with English-Chinese subtitles! Now you can learn to understand native speakers, expand your vocabulary, and improve your pronunciation...

You're listening to this Week in Cardiology from theheart.org, medscape Cardiology.

Basic passive voice

This podcast is intended for healthcare professionals only.

Adverbs of manner

Any views expressed are the presenter's own and do not necessarily reflect the views of WebMD or Medscape.

Hi everyone, this is John Mandrola from theheart.org Medscape Cardiology and this is this Week in Cardiology for February 14, 2026.

This week Ticagulore versus Prosugrel, a new left atrial appendage closure device, PFAAF ablation results, lifestyle intervention in afib, the term provider versus doctor and coffee.

JAMA Cardiology is published Tuxedo 2 trial of Ticagula versus Prosugrel as the second antiplatelet drug with aspirin after coronary stenting in patients who have diabetes and multivesal disease.

Now one twist on the RCT of 1,800 patients was that it was done in India.

Now as a neutral Martian, I like the study question because I see much more Ticagrelar used in Procugrel.

But the German government funded ISAR React 5 trial was highly significant 36% higher rate of death, MI and stroke with Ticagulore versus ProCugrel.

That trial was published in 2019 seven years ago.

Of course I get the fact that it's more complex logistics to give with Prosogril, but gee whiz.

As I have said many times, it shocks me that Ticagulor use is so much greater than Prosegril now.

But that's not the only knock on Ticagulor right in play doh, which was Ticagulor versus Clopidogrel.

The top line was that Ticagulor reduced the primary endpoint of CV, death, MI and stroke by 16%.

But the Plato trial has legendary criticisms and weaknesses right in US patients, there were more deaths in the Ticagular group compared to clopidogrel, the opposite of what was seen globally.

This striking regional difference led to AstraZeneca's first FDA application being rejected and raised fundamental questions about the drug's efficacy.

Second PLATO problem Four countries Israel, us, Georgia and Russia were monitored by independent contract research organizations rather than by Astra.

All four independently monitored countries showed numerically higher rates of the primary outcome in the Ticagalar group compared to clopidogrel.

Third problem, there were also discrepancies between death reports submitted to the FDA 938 deaths versus those provided to trial investigators 905 deaths.

Now some death causes were reclassified in ways that favored Ticagulor.

Clopidogrel deaths switched from non vascular to vascular, while some ticagular vascular deaths were switched to non vascular or unknown.

Fourth problem with Plato the unprecedented all cause mortality reduction hazard ratio 0.78 or 107 more lives saved was so large it prompted an editorial titled do you believe in magic?

Because this benefit exceeded what had been seen when comparing active drugs to placebo in similar trials and seems biologically implausible.

Final problem with Thomas Marciniak An FDA reviewer identified a fundamental paradox.

If Ticagulore provided superior platelet inhibition, patients undergoing early PCI should have benefited most, but

they actually fared worse in the short term compared to clopidogrel patients, contradicting the drug's supposed mechanism of action.

Now my point is that Ticagulor really didn't look much better than Clopidogrel and was clearly worse than Prosogril in the Isar React 5 trial.

This was a study with all comers for stents.

60% had MI, 21% unstable angina and 20% with chronic coronary syndrome.

Okay, the main results at one year the primary endpoint of death, MI, stroke or bleeding occurred in 16.6% taking Ticaglov versus 14.2% taking Prosegril.

The risk difference of 2.3 percentage points worse with Ticagulor failed to meet the prespecified threshold for non inferiority.

Both the MACE endpoints composite of death MI stroke was higher with ticaglor 10.4 versus 8.6% and also major bleeding was higher 8.4 versus 7.14 with ticagulor compared with Prosogril.

And the authors concluded that quote in patients with diabetes and multivesal disease undergoing pci, Ticagulore was not non inferior to Prosogril for the reduction of of the primary outcome at one year.

I've asked colleagues why they favor Ticagula or Viprosugrel and what I usually get are fairly weak answers.

as a cardiologist who does not do stents, I cannot understand why Ticagulore is so dominant over prostagrel in U.S.

And when Plato was so flawed and isoreact clearly showed Prosogril superiority, what is it that makes Ticagulor so sticky?

Despite the empirical evidence, I can't know for sure, but there are potential reasons.

That seems like a weak argument because Dabigatran had the first mover in oral anticoagulants but has been crushed by apixaban and rivaroxaban.

Tachaghilar of course had marketing and messaging.

In fact the twice daily dosing, which is clearly inferior, was positioned as quote, more consistent coverage.

They had guidelines, initial inertia, right?

So once Ticagular was embedded in the guidelines as a Class 1 recommendation, it was hard to change.

There's of course issues with hospital formulary lock in.

Once hospitals negotiate contracts and build protocols, there can become resistance to change.

There's the issue of cognitive biases, right?

So cardiologists who adopted Ticagulor maybe became invested in the decision.

There's always a status quo bias, meaning that if something is working and patients do fine, it's continued.

The main quibble I have with Tuxedo though is the choice to do non inferiority design.

Non inferiority design means that the new treatment should have some advantage, right?

Less costly, less invasive, less burdensome.

I don't really see Ticaglar would justify a non inferiority trial.

The PI professor Bangalore wrote to me that the hypothesis started after Isar react 5 where there was a diabetic subgroup and in that subgroup it seemed to be similar outcomes between Ticagalore and Procugrel.

The Mace outcomes were better on Prosegril, bleeding was lower on Prasugil.

I wonder what a meta analysis of trials would look like.

To me, Prasugal looks to be the better drug when doctors feel they need more than clopidogrel.

Ticagulore Stickiness despite the evidence is a worthy study for students of evidence based medicine.

It's just something curious to think about.

Our next topic is the Veritas study of a dual ceiling left atrial appendage closure device.

Jacky P has published results of the Veritas study of a left atrial appendage closure with a newer generation dual seal occluder made by Abbott.

But before I tell you about this single arm study of 400 patients, we should mention the irony of calling anything in this space by the Latin word for truth.

I say that because the seminal regulatory trial Prevail missed making non inferiority in its first co primary endpoint of stroke, systemic embolism and CV death Warfarin I'm not going to go into that whole thing again.

Let's not relitigate that left atrial appendage closure, like any procedure is going to iterate.

Procedures iterate and they usually get better.

Then the proponents of appendage closure will argue that engineering and technology are going to improve closure rates.

And if you do that, you should improve outcomes.

Now, I don't doubt the former it's going to improve, but

I highly doubt that we're going to have better outcomes.

Now the Abbott bioengineers have come up with a next generation Amulet device.

The study was designed to assess 45 day safety and performance outcomes.

It's a single arm study though they screened 650 patients to include 400 patients.

And that's sort of important because one in three patients were excluded.

The implant success rate was very high, near 100%.

Two thirds of the patients were in sinus rhythm, one third were in afib.

This is strange because if 2/3 were in sinus rhythm, they must have had PAF paroxysmal afib.

So if they have paroxysmal afib, I'm wondering why weren't they ablated to get rid of the AFib?

And then if you get rid of the AFib, there's two trials showing that it's reasonable to stop anticoagulation and then you don't have to have a foreign body in your heart.

Now the main findings were that device related thrombus was found in 2.4% of patients.

Major bleeding in 3 any peri device leak small including or 6%.

There were two pericardial effusions in 400 patients that required drainage and 24 of 400 patients did not have an adequate TEE for assessment.

The authors and editorialist called these results promising.

Now, while they were clearly better than previous Amulet data, I'm not sure that they are all that promising.

If you have device related thrombus, it's a failure, an utter failure because it quadruples stroke risk and it requires oral anticoagulation, which is the point of the procedure, to avoid oral anticoagulation.

So 2.4% to me is a lot of device related thrombus given that only super expert implanters participate in this study.

So a 2.4% DRT rate would likely be much worse in less experienced hands.

Also, a PERI device leak rate of 6% is less than ideal.

We know that if CT had been used the PERI device, leak would likely be higher.