The Rhythm | Issue 7
Issue 7 | Week of 18 May 2026
Heart Failure 2026 closed in Barcelona on 12 May. The week that followed is lighter on the congress calendar but heavier on the questions large trials are not designed to answer.
Cardiology Intelligence Briefing: between the landmarks
Landmark cardiovascular trials earn their authority by defining their populations narrowly. The cost of that discipline is everyone they exclude. This week's five papers each ask a question a landmark trial was not built to answer.
Roughly a quarter of patients with heart failure with preserved ejection fraction (HFpEF) have atrial functional mitral regurgitation (AFMR), a subphenotype no landmark trial has separately tested. PRAISE-MR begins to address this. In 84 randomised patients, sacubitril/valsartan improved exercise pulmonary haemodynamics over six months.2 Two decades of acute decompensated heart failure (ADHF) trials have iterated approaches to decongestion, much of it centred on diuretic strategy. FASTR tested a different therapeutic axis: in a randomised pilot, device-guided automated diuretic delivery with matched sodium chloride replacement produced faster 24-hour natriuresis than optimal diuretic therapy.3
Between the drug trials and the device trials sits the older question of who delivers care over years. ALLEPRE gives one of the strongest answers so far. A pragmatic Italian trial of nurse-coordinated secondary prevention after acute coronary syndrome (ACS) reduced major adverse cardiovascular events (MACE) by 30%, driven by a reduction in nonfatal myocardial infarction (MI).1 The mechanism is what conventional drug trials rarely capture: durable adherence, structured follow-up, and sustained lifestyle change.
The remaining two papers occupy ground randomised trials rarely reach. A Swedish nationwide cohort of 4.27 million people, followed from birth into early adulthood, linked maternal diabetes during pregnancy to early-onset cardiovascular disease (CVD) in offspring, with the strongest associations for heart failure and cerebrovascular disease.4 And in newly diagnosed cardiac amyloidosis, a population arrhythmia trials have never enrolled, prospective implantable loop recorder (ILR) monitoring revealed a Class I pacemaker indication in 17.3% of patients.5
The work between the landmarks matters as much as the landmarks themselves.
