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Welcome to EP Edge Journal Watch — where cardiac electrophysiology meets evidence, precision, and perspective.
Hosted by Dr. Niraj Sharma, this bi-weekly podcast distills high-impact cardiovascular and EP research into clear, clinically meaningful insights. Each episode goes beyond headlines and abstracts to uncover what new studies actually mean for patient care, decision-making, and the future of electrophysiology.
What EP Edge Journal Watch stands for:
Evidence-based practice
Precision electrophysiology
A forward-thinking, edge-driven approach to how we interpret and apply data in real-world clinical settings.
Whether you’re an electrophysiologist, cardiologist, researcher, trainee, or allied health professional, EP Edge Journal Watch brings you the signal — not the noise. Expect sharp summaries, thoughtful commentary, and practical takeaways designed for the busy clinician who wants to stay ahead of the curve
Hi. I'm Mike Lloyd of the Digital Education Committee for the Heart Rhythm Society. I'm super excited today because we are launching a new digital education project. The lead has been really popular. It helps people.
Dr Michael Llyod:It's kinda like a journal club, but it's one article at a time. And so I'm excited now to present a supplement to that, and that is the EP Edge Heart Rhythm Society collaboration. This is more of a a broader look at the wealth of data that comes out every month in terms of a clinical question. So with me today is doctor Niraj Shama. He's the creator of EP Edge.
Dr Michael Llyod:He's gonna talk to us about what what this was all about, how did you start it, and what was your, what was your reason you thought of it?
Dr Niraj Sharma:Right. Thank you, Mike. It's a pleasure to be here. Thank you to start this new pathway, new journey with this collaboration with HRS. So what really happened was started about maybe about a year or so ago.
Dr Niraj Sharma:And at that time, I started really seriously looking into how many articles are presented or come out. And in fact, there's a huge, huge literature that's being pumped out pretty much every month by different journals. And not only is the amount huge, the number of articles that are coming out are coming out at a much faster pace than we ever had before. Right. So there's this lack of adequate curation of these articles.
Dr Niraj Sharma:Now you have these AI algorithms that actually pull up the most cited, the most viewed, but really you need you need a human curating this to to a large extent to determine which of these articles that are coming out are actually clinically meaningful or no.
Dr Michael Llyod:Well, talk talk to me about where this is out now and what what kind of followers or or who's who's following? Is it EP doctors? Is it PAs?
Dr Niraj Sharma:Right. So, yeah, this this whole EP Edge Journal Watch concept started off with a newsletter. Okay. So the newsletter comes out first, and this newsletter comes out in really essentially two forms or two forms. One would be LinkedIn.
Dr Niraj Sharma:Other one is Substack. And tracking these subscribers or how many people are following these newsletters, majority are electrophysiologists, followed by cardiologists. Then you have residents and fellows, and then industry and other people that have an interest in electrophysiology. So the response has been very encouraging, not only in terms of how many people are actually reading contract, if they're actually reading the article or not, and also about the number of downloads we've had on our podcast. So over the last five months, I if you were to ask me, it's grown about 700%
Dr Michael Llyod:that much. Wow.
Dr Niraj Sharma:Huge growth.
Dr Michael Llyod:So give me an idea of the numbers for downloads you have.
Dr Niraj Sharma:The numbers the we we we can get the number of downloads, but what's difficult to get is the true number of subscribers. Yeah. Because what happens is these podcasts go through this distributor and distributor distributes it wherever. So the data that we get in terms of downloads per month, it's about, I would say, for the EP Edge we have two podcasts, but the EP Edge Journal Watch specifically is about a thousand.
Dr Michael Llyod:Wow. That's great. Yeah. That's that's wonderful. I I heard you mention about AI and and why would somebody not be able to just kind of look ask, you know, open evidence, you know, what's the last five journals?
Dr Michael Llyod:Why do you need a human human being to curate this
Dr Niraj Sharma:That's actually I I that's a really good question. I think about this quite often, and I've actually tried this out, and a lot of people have tried it out. When you when you use PubMed, for example, or Open Evidence, Open Evidence does scan journals, but at the when it does scan, it does not really pull out the clinically most meaningful articles that are out there. It would give you the top list or what the new guidelines say. But if you were to ask it, okay.
Dr Niraj Sharma:Tell me, for example, tell me if I don't have access to IV ibutalide or IV procainamide for a pre excited tachycardia, Can I use amiodarone or not? Now this applies to a global population, not necessarily in The US. So if you're in Latin America or India Mhmm. What can I do? Can I give amiodarone safely or not?
Dr Niraj Sharma:That's not gonna be picked up because it just came out maybe two months ago, it's deeply buried in literature. Right. And I can give you so many other I'll give you another example of a of a situation where you can you have, you know, potentially high risk for a device infection occurring for potentially a generator change. And then and you don't have access to an antibacterial pouch. Which arrogant antibacterial arrogant can you use?
Dr Niraj Sharma:So there's a trial out there that says chlorhexidine is equivalent to an antibacterial pouch. So it's articles like this that really don't make the top 10, but they're
Dr Michael Llyod:clinically relevant. Not the not the most sexy topics, but very relevant everyday stuff.
Dr Niraj Sharma:Practice changing. Yeah. And and the whole concept behind behind EP Edge is not only is it practical, it has to be concise because we know all of us are so busy. We hardly have any time to scan through journals. We some of us of us have no time at all.
Dr Niraj Sharma:Right. So the thought was to try and get this podcast done in fifteen, twenty minutes. Now some episodes are are, I wouldn't say less, majority a little bit more than that because there's so much literature out there.
Dr Michael Llyod:So what can our HRS members expect with this collaboration? Once a month, tell me what what do they turn it on on their commute?
Dr Niraj Sharma:Right. They should. So I think this is a great collaboration. HRS is a global organization with a huge outreach. It's not only American.
Dr Niraj Sharma:You have followers in India, Africa, Latin America, Europe. It's a it's a global phenomenon. What EP Edge brings to HRS is the filter, the analysis, and the practical analysis of these trials and a huge exposure that HRS would give this format.
Dr Michael Llyod:So it's kinda like an audible journal watch, but also with some input by you or the whoever the commentator is at putting it into some sort of clinical perspective.
Dr Niraj Sharma:Right. So the way we are going to try this is the the EPA Journal Watch will continue to come out with these trial analysis every week. Right. The fourth week would be a discussion of some relevant trials that were already covered, but a more discussion of these trials that would occur at, I guess, the fourth episode.
Dr Michael Llyod:Wonderful. So with that, are you ready to start our inaugural episode?
Dr Niraj Sharma:Yeah. Let's let's do that. I guess the the the the biggest trial that was that occurred today was the AVANT GUARD trial.
Dr Michael Llyod:Let's do it.
Dr Niraj Sharma:Yeah. So let's talk about it.
Dr Michael Llyod:Ladies and gentlemen, it's my privilege and honor to kick off the inaugural episode EP Edge collaboration with HRS. Our discussant is doctor Niraj Shama. Thank you, Mike. Let's get into it. Let's Alright.
Dr Michael Llyod:Let's talk about AVANT GUARD.
Dr Niraj Sharma:So the AVANT GUARD trial was, I think, presented about six hours ago in our late breaker session at HRS and was simultaneously published in the New England Journal. So when I came out of the trial looking at the presentation, I thought, well, this is a good trial. This would be a good trial for our patients. A lot of our persistent AFib patients, they're trialed on medications first, and if they have to fail antiarrhythmias before they get an ablation. But this trial, as you did something really interesting, it was a first of its kind.
Dr Niraj Sharma:And all credit to the authors for for doing this trial. What they did was they they they took patients with persistent atrial fibrillation standard definition, not not long standing persistent, but persistent AFib less than a year. Uh-huh. And they had never been on an antiarrhythmic drug, so de novo drug naive patients, and then they randomized them into an ablation PFA, Ferro Pulse arm, and antiarrhythmic drug arm. So there's two interesting points that I I kinda realized when I read through the article.
Dr Niraj Sharma:Now I haven't I need to read that article a few more times to get a better gist of what really happened. But Well,
Dr Michael Llyod:in fairness, it just came out. I mean, is hot off the presses.
Dr Niraj Sharma:It is. It is hot off, and it's so much to digest. Right. And you're you're absolutely right. The the the the slides that I saw, there's far more beyond the slides that that that were were disclosed today.
Dr Niraj Sharma:So what what I found was and this was this was in the presentation too, that in October, I think I believe in 2024, I'm not really sure the exact date, but the trial had to be halted. And the reason it was halted because there was an increased number of strokes, and they had a a detailed analysis to why these strokes occurred. I guess one out of the six was because of air embolism, sheath management issues. These these strokes were minor. They all made full recovery, but the the data and safety board had an analysis of the enrollment criteria, and they they made some changes to the enrollment criteria.
Dr Niraj Sharma:And this occurred later on in the trial. So majority of the patients were already enrolled in the initial criteria, I guess a smaller proportion were enrolled in the modified criteria. The criteria was, okay, we're not going to take patients who have a CHARGE VAST equal to or more than four. They had to be on anticoagulation continuously for four weeks prior to ablation. A TEE was needed to rule out clots.
Dr Niraj Sharma:The ACT had to be more than three fifty, during the procedure or or or before ablation started. So all those criteria were were placed in the second part of the trial. So it becomes difficult in at least in my mind to try and equate this as one large trial. Then looking at the at the at the methodology, there was one new feature that was added on, which has previously never been done. So And it becomes difficult for us to to kinda compare trials.
Dr Niraj Sharma:And what they found was asymptomatic. This is the criteria that was added on. Asymptomatic episodes of A fib lasting for more than an hour, equal to or more than an hour, were included as an endpoint. Okay. Okay?
Dr Niraj Sharma:So this was this was new. And, of course, you know, A fib more than equal to thirty seconds or more, the standard criteria was in there. So the the the result was if you look at the two arms, the the pulse field ablation versus the antiarrhythmic. If you look at the classic success rate, AFib equal to more than thirty seconds was equivalent, was the same in the two arms. So but what was different was the asymptomatic episodes in in the the ablation arm went significantly down.
Dr Niraj Sharma:Right. So I guess more analysis needs
Dr Michael Llyod:to be done, but those were my two important takes on the AVANT GUARD. There's a lot of lot of buzz about atrial appendage
Dr Niraj Sharma:Right.
Dr Michael Llyod:Management, atrial appendage management. Some some has come out here, but really in the last two months, three months, talk to me about talk to me about those Yeah.
Dr Niraj Sharma:You know, you're right. March March two thousand twenty six, two big trials came out. Same journal, New England Journal. Both looked at what you know, peripherally, superficially looks like essentially the same concept, but totally different trials. Both were trying to answer this question about, can we get rid of anticoagulation?
Dr Niraj Sharma:And is is is a left atrial appendage closure device enough? So one was the closure AF trial, which was predominant was done in Germany. It was a German trial. And then the CHAMPION AF trial, which was a multicenter, multinational trial. Lot of differences between the two trials, but one of the key differences was the patient selection.
Dr Niraj Sharma:In in the closure AF trial, there were really sick patients. So the Hasbler's score was three plus. The Chadvas score was really high. So it's a it was a classic group of patients that we would be hesitant to give them long term anticoagulants. Right.
Dr Niraj Sharma:So that trial turned out to be non inferior. So meaning left atrial appendage closure devices offer no additional benefit to anti antiarrhythmic sorry, to anticoagulants.
Dr Michael Llyod:Not non inferior.
Dr Niraj Sharma:Not non inferior.
Dr Michael Llyod:Yeah. It's a hard concept to wrap my head around. The the trial difference is also funding. I mean, one was industry
Dr Niraj Sharma:Right.
Dr Michael Llyod:One was not.
Dr Niraj Sharma:Correct. So that's true. I don't know how much weight you can give to that, but that's true. The champion was funded by by by a vendor, and the closure AF was not. Yeah.
Dr Niraj Sharma:So there was clearly maybe maybe maybe not there was bias, but clearly, that's one issue. But the champion trial included patients where, currently, you and I would not really think of taking them off anticoagulation. There were lower Hasbler score, low CHARDS VASc score, really a person who's doing well. So they included a different relatively healthy population. And it's interesting, Mike, that both these two trials, drove not not inferior or non inferior to was bleeding.
Dr Niraj Sharma:So in the closure AF, there was high periprocedural bleeding. Now, in the CHAMPION AF trial, they did not include periprocedural bleeding.
Dr Michael Llyod:Right, that was That
Dr Niraj Sharma:was not part, not of the primary cord, but of the secondary analysis. So if you included that into the the the primary analysis, then it wouldn't be, you know, it wouldn't be a non not non inferior. So and also, the other issue is the clinically relevant non major bleeding. That was another issue with the champion trial. If you incorporated that too, it again would be not inferior.
Dr Niraj Sharma:So put it put it
Dr Michael Llyod:into some clinical perspective then. Are you going to start offering appendage occlusion to people as a viable alternative to anticoagulation or should we reserve it for people who have a problem with anticoagulation?
Dr Niraj Sharma:Right. So, Mike, that's a really good question. Based on these two trials and and it's it's really, you know, important to interpret these trial in the context of patients that were actually studied. So the the patients that truly need to be off anticoagulation, the frail, elderly, high haz blood, the Closure AF trial said no. Right.
Dr Niraj Sharma:Right? So it's a conundrum that we're in. Right? So if your institution and your own data set says that your complication, the periprocedural complication rate in that subset of patient is good, then maybe you should. But it really boils down to what your complication rate and what the shared decision is that you have with the patient.
Dr Michael Llyod:Okay. I'm gonna put you on the spot and I I we've we've talked about this in in our journal clubs. The summation of closure and champion, is this a is this a strike against or a victory for atrial appendage? Strike against or victory for?
Dr Niraj Sharma:I think it's the status quo. It's the status quo.
Dr Michael Llyod:Good neutral answer.
Dr Niraj Sharma:Yeah. It's the status quo. Yeah. So and I think that is the honest answer. Right.
Dr Niraj Sharma:I did I don't I don't think the champion changes anything. I think it the closure does put caution does put caution in my mind.
Dr Michael Llyod:I wanna talk about one final thing before we wrap it up, and that is what about the idea of just stopping the blood thinners after a while? They're doing well. Yeah. Put that into some perspective. Maybe OCEAN?
Dr Niraj Sharma:Yeah. So last year, we had two trials that came out pretty close to each other, the the OCEAN trial and the ALONE AF trial. Now both these trials so the ALONE AF was a Korean trial, and the OCEAN was was actually a Canadian trial with multi multi site enrollment. So the concept in both these trials, however, was the same. They said, well, in low or intermediate risk score, CHARED VASc score of around two or slightly more than two, patients that have had apparently a successful ablation, AF ablation, can we stop their anticoagulation?
Dr Niraj Sharma:Right. What happened with the in the OCEAN trial, the trial was was stopped prematurely because the number of instances of stroke were so so low, and the bleeding risk was high. So it was felt that we'll never meet meet our endpoints, so the trial was stopped. So but it it it showed us the fact that when you do an ablation in low risk, growth chart VAS score, and you have a successful ablation, our monitoring becomes really important. How how you monitor?
Dr Niraj Sharma:Do you do a loop recorder? And in fact, which loop recorder do you use as another discussion? But in these trials, there was no loop recorder implantation, so the it was intermittent monitoring. So in that trial, the the bleeding risk with rivaroxaban was the drug was the DOAC that was used was higher, and the stroke was risk was low. And it suggested maybe after, again, a shared decision in these low risk population of stroke who have apparently a successful ablation, you could consider it.
Dr Niraj Sharma:And the ALONE did the same, although the ALONE trial went all the way to complete completion, but the the the results were essentially the same, meaning that the bleeding risk was far more than the stroke risk. So the the the balance was more bleeding. Do you wanna take more bleeding versus a very lower risk for stroke?
Dr Michael Llyod:Very low risk for stroke. Does that hurt you cognitively?
Dr Niraj Sharma:So that's the trial that was presented yesterday, the the ALONE AF Substudy looking at cognitive decline. And that study was actually a really interesting study. Of course, the cohort was the same patients that were in the parent ALONE AF trial. But what it showed was it made no difference cognitive wise whether you were on anticoagulation or not. But what it did show surprisingly in a sub analysis of this trial was that if you were in sinus rhythm, it did reduce your cognitive decline.
Dr Niraj Sharma:So maintaining sinus rhythm had a had a benefit. So maybe another trial.
Dr Michael Llyod:Maybe not the drug, but the rhythm.
Dr Niraj Sharma:The rhythm. Exactly. Exactly.
Dr Michael Llyod:We can expect every month a distillation of doctor Sharma's content on EP Edge through HRS EP Edge collaboration. Look for it in our podcasts along with the lead And, Niraj, thank you. I'm excited to keep this going.
Dr Niraj Sharma:Absolutely. Great pleasure. Thank you.