1. The Big Beta-Blocker Reversal
Trials supporting the use of beta-blockers after myocardial infarction (MI) were performed before the reperfusion era. Forty years on, MI is a different condition.
Two trials published this year have reversed this recommendation for patients with preserved left ventricular function. In the Swedish-led REDUCE-AMI trial, more than 5000 post-MI patients were randomized to beta-blocker or no beta-blocker. In 3.5 years of follow-up, the primary endpoint of death or new MI did not statistically differ between treatment groups.
The French ABYSS trial was a bit harder to interpret, but largely supported the findings of REDUCE-AMI. The ABYSS trialists randomized nearly 3800 post-MI patients to either stop their beta-blocker or continue it. The primary endpoint of death, MI, stroke or hospitalization for cardiovascular (CV) reasons was 24% in the interruption arm vs 21% in the continuation group. The higher rate of events in the interruption arm was nearly completely driven by hospitalizations. Death, MI and stroke rates were not different, mirroring REDUCE-AMI. ABYSS was open-label. Because patients in the interruption arm knowingly had a treatment subtracted, they were more likely to be anxious about symptoms, thereby driving the hospitalization arm.
Few stories better illustrate the concept that evidence should have an expiration date.
2. Limits of Revascularization in Stable CAD Upheld
I believe the REVIVED-BCIS2 trial comparing percutaneous coronary intervention (PCI) with medical therapy is one of the most important trials in the past decade. Patients were perfect for revascularization; they had multivessel disease, PCI-amenable anatomy, viable myocardium, and left ventricular dysfunction. I’ve never seen a US doctor not revascularize such a patient. Yet in REVIVED-BCIS2, PCI plus optimal medical therapy did not reduce the primary outcome of death or hospitalization for heart failure over optimal medical therapy alone.
This year, the investigators published multiple substudies — all of which upheld the primary findings. A cost-effectiveness analysis found that the probability of PCI being cost-effective was zero. A substudy looking at patients with complete anatomical or viability-guided revascularization found no benefit over medical therapy. A prespecified analysis of PCI on health status found that PCI did not improve the hierarchical composite of death, hospitalization for heart failure, and health status at 2 years. This study did show an improvement in Kansas City Cardiomyopathy Questionnaire overall summary score at 6 months, but the benefit was not sustained at 1- or 2-year follow-up.
When I wear my neutral Martian hat, it shocks me how often the results of this trial are ignored — even 2 years after the original publication. The problem comes when you walk into the cath lab and see such an angiogram. It triggers parts of your brain to scream "Fix those lesions." Our brains can’t seem to disentangle the gnarly angiogram with the slew of nonsignificant revascularization trials (CASS, VA Cooperative, STICH at 5 years, COURAGE, BARI-2D, ISCHEMIA). It may take a generation or two to believe REVIVED-BCIS2.
3. Possible Name Change Coming for ST-Elevation MI
Few treatments in all of biomedicine have been more elegant and beneficial than urgent PCI for patients with MI. Opening an acutely closed coronary artery can transform an MI from a possible death sentence to an inconvenience. This miracle turns on recognition of ST-segment elevation (STEMI) on a standard EKG, which is imperfect.
In November, JACC: Advances published a review paper led by Jesse McLaren, an emergency medicine specialist, in which the authors argue for a name change from STEMI to "occlusion MI" (OMI). We’ve long known that many patients with acutely closed coronary arteries do not exhibit ST-segment elevation and that nearly one third of patients diagnosed with non–STEMI (NSTEMI) have an acutely closed artery. The labels STEMI and NSTEMI hamper our ability to improve this misdiagnosis — when an occlusion MI is missed and myocardial damage occurs, it is simply called NSTEMI.
The proposed name change to "OMI" vs "non-OMI" could bolster quality improvement efforts because missed occlusions could no longer be justified as NSTEMI. Integral to this proposed paradigm change is a new focus on the 12-lead ECG. Human reading could improve, but we are also on the cusp of AI-based ECG reading, such as the Queen of Hearts application, or even single-lead ECG detection of OMI.
Skeptics of this paradigm change rightly point to lack of benefit for urgent PCI in patients with NSTEMI. I would argue, however, this is surely due to the heterogeneity of NSTEMI. Enriching a population of patients with OMI improves the odds of benefit for urgent PCI. If I had an acute coronary syndrome, I’d rather my doctors think occlusion MI vs STEMI/STEMI. The answer, of course, will only come via randomized trials of the two strategies.
4. GLP-1 Drugs Continue to Win, Except in HFpEF
In March, the US Food and Drug Administration (FDA) approved the glucagon-like peptide 1 (GLP-1) receptor agonist semaglutide for reduction of major clinical outcomes in patients with obesity and established heart disease on the basis of the SELECT trial results.
The placebo-controlled FLOW trial of semaglutide in patients with chronic kidney disease and diabetes reported clinically meaningful and statistically robust reductions in a primary renal endpoint, CV death, and all-cause death. Notably, the mean body mass index of patients in this trial was only 32.
In patients with obesity and sleep apnea, the SURMOUNT-OSA reported that the dual GLP-1/glucose-dependent insulinotropic peptide agonist (GIP) tirzepatide reduced the apnea-hypopnea index, body weight, hypoxic burden, high-sensitivity C-reactive protein level, and systolic blood pressure compared with placebo.
A recent press release noted that tirzepatide beat semaglutide for weight loss in the head-to-head comparison study called SURMOUNT-5.
Investigators estimated that 40% of US adults — some 137 million people — are eligible to take the drug class.
Like our calendars, internal medicine and cardiology may well be defined as before and after GLP-1 drugs.
5. SUMMIT: An HFpEF Trial That Fails to Impress
But even the great GLP-1 drugs may struggle in heart failure with preserved ejection fraction (HFpEF), as other drugs have.
At the American Heart Association meeting in November, the SUMMIT trial delivered another positive result for the GLP-1 drug class: Tirzepatide reduced an outcome of CV death and heart failure events in patients with obesity and HFpEF compared with placebo. The trial met with glowing headlines. Key opinion leaders called it practice-changing. Indeed it was the first GLP-1 trial in heart failure with clinical outcomes.
Yet the trial had numerous problems, which I covered. These included no reduction in CV death and an incredibly small number of heart failure events. The irony is that Milton Packer, the principal investigator of the SUMMIT trial, wrote an editorial in 2018 titled "Building Castles in the Sky," in which he criticized an atrial fibrillation (AF) ablation trial for having so few primary outcome events. Compared with some other drug trials in HFpEF, SUMMIT had nearly 10-fold fewer primary outcome events.
GLP-1 and GIP drugs may benefit patients with HFpEF, but it will require far larger trials to call them disease-modifying.
6. A Positive Trial in HFpEF — Sort Of
The FDA approved the nonsteroidal mineralocorticoid receptor antagonist finerenone in 2021 to reduce the risk for renal and cardiac outcomes in patients with chronic kidney disease and diabetes based on the FIDELIO-DKD trial.
This year, the heart failure community celebrated the positive results of the placebo-controlled FINEARTS-HF trial in patients with mildly reduced or preserved ejection fraction. Positive results in HFpEF trials are few and far between. But. There is a "but."
The big story with FINEARTS-HF is how a positive trial fails to clarify what clinicians should do — for two reasons.
One is the choice of placebo rather than spironolactone as a comparator. We know from the Americas portion of the TOPCAT trial that spironolactone also works in HFpEF. The second issue with FINEARTS-HF is that the small (16%) reduction in the primary endpoint was driven by the softer endpoint of heart failure events. CV death rates were not statistically different. The problem with using hospitalization (or urgent visits) as an endpoint is that we don’t know all-cause hospitalization. This lack of reporting is a chronic problem with heart failure trials. The curious thing about FINEARTS-HF is that the authors published multiple secondary analyses of the trial. None had all-cause hospitalization.
Like so many new therapies, finerenone poses a value dilemma. We have mineralocorticoid receptor antagonists that cost almost nothing. Should we not start with the low-cost drugs?
7. Multimorbidity Is a Problem for Modern Cardiologists
I began cardiology in the heyday of evidence-based medicine, right after the CAST trial. The problem we have today is that much of our evidence was obtained in younger, mostly male patients. Owing to progress in all fields of medicine, the modern cardiologist often sees older patients who have multiple comorbid conditions.
In the March 29 episode of This Week in Cardiology, I reviewed two elegant studies that underscore the challenge of translating evidence to our patients.
One was a meta-analysis of 12 trials of vitamin K antagonists (VKAs), mostly warfarin, vs placebo or aspirin in patients with AF. The authors estimated the risk reduction with VKAs using our standard guideline-endorsed CHA2DS2-VASc risk score and a model that employed a competing risk for death. They found that VKA benefits were misestimated with CHA2DS2-VASc, which does not account for the competing risk for death nor decelerating treatment benefit over time. And the overestimation was greatest when life-expectancy was low.
My friend and frequent co-author, Andrew Foy, MD, led another study looking at competing risks in eight major trials. Using the Charlson Comorbidity Index (CCI) as a measure of competing risks, his team found that seminal trials mostly enrolled patients with low comorbidity. And about one third of trials had clinically relevant interactions between the CCI score and treatment effect.
For instance, in the SCD-HeFT trial of primary prevention implantable cardioverter-defibrillator therapy in patients with heart failure, the majority of treatment benefit was in patients with low CCI. In AFFIRM, the rate vs rhythm control trial in AF, which found a nonsignificant 15% higher rate of death in the rhythm control arm, there was clear harm from rhythm control in those with a high CCI score.
To repeat: The challenge of the modern cardiologist is not having something to offer, but whether it should be offered in older patients with multiple other conditions.
8. Tricuspid Valve Interventions
It was a big year for percutaneous tricuspid valve interventions. The FDA approved both the first transcatheter tricuspid valve replacement and transcatheter edge-to-edge repair (TEER) system.
The good news is that there are patients with tricuspid valve regurgitation who may benefit from these far less invasive approaches.
The bad news is that the regulatory trials were a scientific mess. Both the valve replacement and TEER trials found no differences in clinical outcomes. Benefit was driven by quality-of-life measures, which are nearly useless because neither trial had a placebo-control (sham) arm.
The good news/bad frame creates tension, doesn’t it? You want to have innovative ways to treat selected patients, but once approved, with a weak evidentiary base, there is the potential for overuse and harm. Worrisome, especially, is the much higher pacemaker and major bleeding rates with the tricuspid valve replacement.
9. DanGer Shock Saves the Microaxial Flow Pump
The purported benefit of the Impella microaxial flow pump (Abiomed) in cardiogenic shock is that it provides organ perfusion during the crucial time between myocardial injury and recovery after percutaneous coronary intervention. The idea makes great sense.
But the pump was approved through the soft 510(k) FDA pathway — without trial-level evidence. Through extensive marketing and payment incentives, its use ballooned. Even though two trials failed to show it as better than the intra-aortic balloon pump—and the latter had also failed against medical therapy.
DanGer Shock trialists took 11 years to randomize 360 patients with post-MI cardiogenic shock to either the flow pump or standard care. The primary endpoint of mortality at 6 months was 26% lower in the flow pump arm. The P value was.04.
The take-home message was that if you are extremely careful in choosing patients, the flow pump can help. That is a message consistent with the common statement from interventional cardiologists: "Some patients wouldn’t make it out of the cath lab without support."
DanGer Shock makes the year-end list not only because it found benefit but also because it exemplifies good medical science. Our field should demand such evidence before widespread adoption of a medical device.
10. Pulsed Field Ablation Transforms Electrophysiology
In February, the FDA approved a new way to ablate atrial myocardium. Pulsed field ablation (PFA) uses electrical energy rather than thermal energy. I was skeptical, but after using PFA this year, it’s hard not to be excited.
European electrophysiologists have had a head start with PFA, having embraced the new technology for 2 years. Although trials and observational studies show little difference in efficacy or the incidence of common complications compared with thermal ablations, two big advantages of PFA are its cardioselectivity and speed. In my view, cardioselectivity is huge because it reduces (perhaps eliminates) the worry of causing death from thermal injury to the esophagus.
This year saw a furious race amongst industry to innovate and win market advantage in the AF ablation market. I may be wrong, but having used PFA for half the year, I can’t imagine doing AF ablation in the old way.
The problem of course is that ablating myocardium gets us no closer to understanding the pathophysiology of AF. Twenty years of AF ablation has led us no closer to understanding the upstream causes of AF.
John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence.
COMMENTARY
Mandrola’s Top 10 Stories in 2024
DISCLOSURES
| December 11, 20241. The Big Beta-Blocker Reversal
Trials supporting the use of beta-blockers after myocardial infarction (MI) were performed before the reperfusion era. Forty years on, MI is a different condition.
Two trials published this year have reversed this recommendation for patients with preserved left ventricular function. In the Swedish-led REDUCE-AMI trial, more than 5000 post-MI patients were randomized to beta-blocker or no beta-blocker. In 3.5 years of follow-up, the primary endpoint of death or new MI did not statistically differ between treatment groups.
The French ABYSS trial was a bit harder to interpret, but largely supported the findings of REDUCE-AMI. The ABYSS trialists randomized nearly 3800 post-MI patients to either stop their beta-blocker or continue it. The primary endpoint of death, MI, stroke or hospitalization for cardiovascular (CV) reasons was 24% in the interruption arm vs 21% in the continuation group. The higher rate of events in the interruption arm was nearly completely driven by hospitalizations. Death, MI and stroke rates were not different, mirroring REDUCE-AMI. ABYSS was open-label. Because patients in the interruption arm knowingly had a treatment subtracted, they were more likely to be anxious about symptoms, thereby driving the hospitalization arm.
Few stories better illustrate the concept that evidence should have an expiration date.
2. Limits of Revascularization in Stable CAD Upheld
I believe the REVIVED-BCIS2 trial comparing percutaneous coronary intervention (PCI) with medical therapy is one of the most important trials in the past decade. Patients were perfect for revascularization; they had multivessel disease, PCI-amenable anatomy, viable myocardium, and left ventricular dysfunction. I’ve never seen a US doctor not revascularize such a patient. Yet in REVIVED-BCIS2, PCI plus optimal medical therapy did not reduce the primary outcome of death or hospitalization for heart failure over optimal medical therapy alone.
This year, the investigators published multiple substudies — all of which upheld the primary findings. A cost-effectiveness analysis found that the probability of PCI being cost-effective was zero. A substudy looking at patients with complete anatomical or viability-guided revascularization found no benefit over medical therapy. A prespecified analysis of PCI on health status found that PCI did not improve the hierarchical composite of death, hospitalization for heart failure, and health status at 2 years. This study did show an improvement in Kansas City Cardiomyopathy Questionnaire overall summary score at 6 months, but the benefit was not sustained at 1- or 2-year follow-up.
When I wear my neutral Martian hat, it shocks me how often the results of this trial are ignored — even 2 years after the original publication. The problem comes when you walk into the cath lab and see such an angiogram. It triggers parts of your brain to scream "Fix those lesions." Our brains can’t seem to disentangle the gnarly angiogram with the slew of nonsignificant revascularization trials (CASS, VA Cooperative, STICH at 5 years, COURAGE, BARI-2D, ISCHEMIA). It may take a generation or two to believe REVIVED-BCIS2.
3. Possible Name Change Coming for ST-Elevation MI
Few treatments in all of biomedicine have been more elegant and beneficial than urgent PCI for patients with MI. Opening an acutely closed coronary artery can transform an MI from a possible death sentence to an inconvenience. This miracle turns on recognition of ST-segment elevation (STEMI) on a standard EKG, which is imperfect.
In November, JACC: Advances published a review paper led by Jesse McLaren, an emergency medicine specialist, in which the authors argue for a name change from STEMI to "occlusion MI" (OMI). We’ve long known that many patients with acutely closed coronary arteries do not exhibit ST-segment elevation and that nearly one third of patients diagnosed with non–STEMI (NSTEMI) have an acutely closed artery. The labels STEMI and NSTEMI hamper our ability to improve this misdiagnosis — when an occlusion MI is missed and myocardial damage occurs, it is simply called NSTEMI.
The proposed name change to "OMI" vs "non-OMI" could bolster quality improvement efforts because missed occlusions could no longer be justified as NSTEMI. Integral to this proposed paradigm change is a new focus on the 12-lead ECG. Human reading could improve, but we are also on the cusp of AI-based ECG reading, such as the Queen of Hearts application, or even single-lead ECG detection of OMI.
Skeptics of this paradigm change rightly point to lack of benefit for urgent PCI in patients with NSTEMI. I would argue, however, this is surely due to the heterogeneity of NSTEMI. Enriching a population of patients with OMI improves the odds of benefit for urgent PCI. If I had an acute coronary syndrome, I’d rather my doctors think occlusion MI vs STEMI/STEMI. The answer, of course, will only come via randomized trials of the two strategies.
4. GLP-1 Drugs Continue to Win, Except in HFpEF
In March, the US Food and Drug Administration (FDA) approved the glucagon-like peptide 1 (GLP-1) receptor agonist semaglutide for reduction of major clinical outcomes in patients with obesity and established heart disease on the basis of the SELECT trial results.
The placebo-controlled FLOW trial of semaglutide in patients with chronic kidney disease and diabetes reported clinically meaningful and statistically robust reductions in a primary renal endpoint, CV death, and all-cause death. Notably, the mean body mass index of patients in this trial was only 32.
In patients with obesity and sleep apnea, the SURMOUNT-OSA reported that the dual GLP-1/glucose-dependent insulinotropic peptide agonist (GIP) tirzepatide reduced the apnea-hypopnea index, body weight, hypoxic burden, high-sensitivity C-reactive protein level, and systolic blood pressure compared with placebo.
A recent press release noted that tirzepatide beat semaglutide for weight loss in the head-to-head comparison study called SURMOUNT-5.
Investigators estimated that 40% of US adults — some 137 million people — are eligible to take the drug class.
Like our calendars, internal medicine and cardiology may well be defined as before and after GLP-1 drugs.
5. SUMMIT: An HFpEF Trial That Fails to Impress
But even the great GLP-1 drugs may struggle in heart failure with preserved ejection fraction (HFpEF), as other drugs have.
At the American Heart Association meeting in November, the SUMMIT trial delivered another positive result for the GLP-1 drug class: Tirzepatide reduced an outcome of CV death and heart failure events in patients with obesity and HFpEF compared with placebo. The trial met with glowing headlines. Key opinion leaders called it practice-changing. Indeed it was the first GLP-1 trial in heart failure with clinical outcomes.
Yet the trial had numerous problems, which I covered. These included no reduction in CV death and an incredibly small number of heart failure events. The irony is that Milton Packer, the principal investigator of the SUMMIT trial, wrote an editorial in 2018 titled "Building Castles in the Sky," in which he criticized an atrial fibrillation (AF) ablation trial for having so few primary outcome events. Compared with some other drug trials in HFpEF, SUMMIT had nearly 10-fold fewer primary outcome events.
GLP-1 and GIP drugs may benefit patients with HFpEF, but it will require far larger trials to call them disease-modifying.
6. A Positive Trial in HFpEF — Sort Of
The FDA approved the nonsteroidal mineralocorticoid receptor antagonist finerenone in 2021 to reduce the risk for renal and cardiac outcomes in patients with chronic kidney disease and diabetes based on the FIDELIO-DKD trial.
This year, the heart failure community celebrated the positive results of the placebo-controlled FINEARTS-HF trial in patients with mildly reduced or preserved ejection fraction. Positive results in HFpEF trials are few and far between. But. There is a "but."
The big story with FINEARTS-HF is how a positive trial fails to clarify what clinicians should do — for two reasons.
One is the choice of placebo rather than spironolactone as a comparator. We know from the Americas portion of the TOPCAT trial that spironolactone also works in HFpEF. The second issue with FINEARTS-HF is that the small (16%) reduction in the primary endpoint was driven by the softer endpoint of heart failure events. CV death rates were not statistically different. The problem with using hospitalization (or urgent visits) as an endpoint is that we don’t know all-cause hospitalization. This lack of reporting is a chronic problem with heart failure trials. The curious thing about FINEARTS-HF is that the authors published multiple secondary analyses of the trial. None had all-cause hospitalization.
Like so many new therapies, finerenone poses a value dilemma. We have mineralocorticoid receptor antagonists that cost almost nothing. Should we not start with the low-cost drugs?
7. Multimorbidity Is a Problem for Modern Cardiologists
I began cardiology in the heyday of evidence-based medicine, right after the CAST trial. The problem we have today is that much of our evidence was obtained in younger, mostly male patients. Owing to progress in all fields of medicine, the modern cardiologist often sees older patients who have multiple comorbid conditions.
In the March 29 episode of This Week in Cardiology, I reviewed two elegant studies that underscore the challenge of translating evidence to our patients.
One was a meta-analysis of 12 trials of vitamin K antagonists (VKAs), mostly warfarin, vs placebo or aspirin in patients with AF. The authors estimated the risk reduction with VKAs using our standard guideline-endorsed CHA2DS2-VASc risk score and a model that employed a competing risk for death. They found that VKA benefits were misestimated with CHA2DS2-VASc, which does not account for the competing risk for death nor decelerating treatment benefit over time. And the overestimation was greatest when life-expectancy was low.
My friend and frequent co-author, Andrew Foy, MD, led another study looking at competing risks in eight major trials. Using the Charlson Comorbidity Index (CCI) as a measure of competing risks, his team found that seminal trials mostly enrolled patients with low comorbidity. And about one third of trials had clinically relevant interactions between the CCI score and treatment effect.
For instance, in the SCD-HeFT trial of primary prevention implantable cardioverter-defibrillator therapy in patients with heart failure, the majority of treatment benefit was in patients with low CCI. In AFFIRM, the rate vs rhythm control trial in AF, which found a nonsignificant 15% higher rate of death in the rhythm control arm, there was clear harm from rhythm control in those with a high CCI score.
To repeat: The challenge of the modern cardiologist is not having something to offer, but whether it should be offered in older patients with multiple other conditions.
8. Tricuspid Valve Interventions
It was a big year for percutaneous tricuspid valve interventions. The FDA approved both the first transcatheter tricuspid valve replacement and transcatheter edge-to-edge repair (TEER) system.
The good news is that there are patients with tricuspid valve regurgitation who may benefit from these far less invasive approaches.
The bad news is that the regulatory trials were a scientific mess. Both the valve replacement and TEER trials found no differences in clinical outcomes. Benefit was driven by quality-of-life measures, which are nearly useless because neither trial had a placebo-control (sham) arm.
The good news/bad frame creates tension, doesn’t it? You want to have innovative ways to treat selected patients, but once approved, with a weak evidentiary base, there is the potential for overuse and harm. Worrisome, especially, is the much higher pacemaker and major bleeding rates with the tricuspid valve replacement.
9. DanGer Shock Saves the Microaxial Flow Pump
The purported benefit of the Impella microaxial flow pump (Abiomed) in cardiogenic shock is that it provides organ perfusion during the crucial time between myocardial injury and recovery after percutaneous coronary intervention. The idea makes great sense.
But the pump was approved through the soft 510(k) FDA pathway — without trial-level evidence. Through extensive marketing and payment incentives, its use ballooned. Even though two trials failed to show it as better than the intra-aortic balloon pump—and the latter had also failed against medical therapy.
DanGer Shock trialists took 11 years to randomize 360 patients with post-MI cardiogenic shock to either the flow pump or standard care. The primary endpoint of mortality at 6 months was 26% lower in the flow pump arm. The P value was.04.
The take-home message was that if you are extremely careful in choosing patients, the flow pump can help. That is a message consistent with the common statement from interventional cardiologists: "Some patients wouldn’t make it out of the cath lab without support."
DanGer Shock makes the year-end list not only because it found benefit but also because it exemplifies good medical science. Our field should demand such evidence before widespread adoption of a medical device.
10. Pulsed Field Ablation Transforms Electrophysiology
In February, the FDA approved a new way to ablate atrial myocardium. Pulsed field ablation (PFA) uses electrical energy rather than thermal energy. I was skeptical, but after using PFA this year, it’s hard not to be excited.
European electrophysiologists have had a head start with PFA, having embraced the new technology for 2 years. Although trials and observational studies show little difference in efficacy or the incidence of common complications compared with thermal ablations, two big advantages of PFA are its cardioselectivity and speed. In my view, cardioselectivity is huge because it reduces (perhaps eliminates) the worry of causing death from thermal injury to the esophagus.
This year saw a furious race amongst industry to innovate and win market advantage in the AF ablation market. I may be wrong, but having used PFA for half the year, I can’t imagine doing AF ablation in the old way.
The problem of course is that ablating myocardium gets us no closer to understanding the pathophysiology of AF. Twenty years of AF ablation has led us no closer to understanding the upstream causes of AF.
John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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