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Thread: To me, the most stunning report from #ESCCongress thus far: RATE-AF trial
Older pts w/ permanent AF + shortness of breath. (there are lots of these pts).
Rate control is crucial
In 2020, most receive beta-blockers.
But BB can cause dyspnea.
What about dig?
Gulp! 1/
Rate-AF randomized these pts to bb vs digoxin. Here is the protocol paper: bmjopen.bmj.com/content/bmjope…
Crucially they looked at quality of life. That's a really important outcome.
The results shocked me. Look at heart rates. Dig isn't supposed to be this good.
Here are the money slides. Short story: better quality and of life and even bnp on dig vs BB
Given the oodles of (flawed) observational data suggesting dig worsens outcomes, the authors looked at clinical events. These are not powered formally, but look... again, better with digoxin.
The authors conclude that dig be moved to first line. This is a nice study but that may be a bit of big leap. That said, at minimum, this evidence takes dig out of the poison category. We ought to have a confirmatory trial.
I have written on the weakness of the data that relegated dig to the 'avoid' category. The RCT level evidence for the drug is neutral. Observational data is flawed by indication bias.

medscape.com/viewarticle/91…
Finally, dig needs to be used carefully. Which you can do in a trial but harder in real world. This is an Imp point for external validity.
@theheartorg @escardio @DrAfzalSohaib @DRTomlinsonEP @majazayeri @Moscoso_Costa
@nmsdegroot @Dominik_Linz @sgjeffrey
Oh, I forgot the link to the presentation esc2020.escardio.org/detail/videos/…
Hey @RogueRad — a week makes a big difference in ratios!
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John Mandrola, MD
@drjohnm
Need help from trial methods people. I ran across this amazing paper by @phlegmfighter et al looking at consequences of recommendations in the design and interpretation of Non-inferiority trials. pubmed.ncbi.nlm.nih.gov/28875400/
THEY SUGGEST SYSTEMIC BIASES.
Thread Image
If you put the new treatment on the left side of the interpretative diagram, there are four ways to make Non-inferiority. Scenarios 1-4. but.... Image
They show that if the convention were to put the active control on the left side of the diagram, make the new treatment the control, you would bias strongly toward the control (thus making NI more difficult to reach). No change in data, just the mirror image here: Image
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John Mandrola, MD
@drjohnm
Thread coming on one way docs might add value to the #COVID19 crisis: critical appraisal.
I wrote a critique of a flawed study published in a major journal. The study reported on the assoc of anticoagulant use and death in COVID pts.
medscape.com/viewarticle/93…
It is an important topic b/c numerous studies have suggested a high rate of clot-related complications in acute #COVID19 illness. it makes sense to consider anti-coagulants...
But anticoagulants come with harms--bleeding. What's more, in non-COVID pts we know that there are actual clots that we are treating. Infection control issues sometimes prevents knowing whether a person w/ #COVID19 actually has clots.
Read 13 tweets
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John Mandrola, MD
@drjohnm
Oh my, @theheartorg and @Medscape are crushing it with not one but two great columns on the limits of testing for #covid19 --This is important on many levels, not just for the virus but also for literacy of medical testing.
Very Brief Thread -- I am excited
In the first column, my friend @anish_koka a doc w #SkinInTheGame writes on why we can't test ourselves out of the #COVID19 crisis. medscape.com/viewarticle/92…
He debunks the Hammer/Dance figures with help from @AndrewFoy82 who does an actual correlation line --
There is more than in this column than just debunking of analyses in which one circles the dots that fit their narrative. Take a look -- Now to the second column.
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