Marco's Morning Report — Sunday, August 30, 2026

Morning, Marco. Unusual day: essentially the whole briefing comes out of one building in Munich. The ESC Congress opened Friday and by last night it had already retired the phrase "type 2 MI," deleted HFmrEF from the vocabulary, told us what a statin actually buys a healthy 78-year-old, and handed you a genuinely hard bedside question about brain bleeds and blood thinners. Three of these change words you write in charts. Read A, skim the debate, then sleep.

A · Top Stories

Trial · Geriatrics

STAREE: atorvastatin cut cardiovascular events 30% in healthy over-70s — and changed nothing about how long they stayed independent

Presented Saturday at ESC and published simultaneously in NEJM, STAREE randomized roughly 5,000 community-dwelling adults over 70 — no known cardiovascular disease, no diabetes, no dementia — to atorvastatin 40 mg or placebo for about six years. Major cardiovascular events fell 30%, driven mainly by nonfatal events. The co-primary endpoint the trial was actually built around, disability-free survival, was unchanged. Muscle, liver, and diabetes-related adverse events were more common on atorvastatin; serious adverse events were balanced. HCPLive · ACC summary

Why it matters to you: this is the first real randomized answer to the question you inherit every night — the 81-year-old on a primary-prevention statin nobody has revisited since 2011, now admitted with weakness and a creatinine of 1.9. STAREE says the drug is doing something (fewer nonfatal MIs and strokes) but does not buy the outcome families actually ask about (more time living independently). That's a much more honest sentence than either "statins don't help old people" or "everyone stays on it."

Action: this is deprescribing language, not a deprescribing mandate. Next time you're holding a statin for myalgias or a transaminase bump in someone over 75 with no CAD, the discharge note can now say what the trade actually is — fewer nonfatal events, no change in disability-free survival — instead of deferring entirely to the PCP.

Definition · Documentation

"Type 2 MI" is gone: the Fifth Universal Definition replaces numbered MI types with primary, secondary, and procedure-related

The ESC, ACC, AHA and World Heart Federation jointly released the Fifth Universal Definition of Myocardial Infarction on Friday, published in JACC and Circulation. The Types 1–5 numbering introduced in 2012 and expanded in 2018 is retired in favor of three clinical categories: primary (atherothrombotic), secondary (oxygen supply–demand imbalance from another acute condition — what you've been calling type 2), and procedure-related. The document also formalizes sex-specific troponin thresholds, pushes imaging to establish etiology, and comes with dedicated ICD-11 codes. HCPLive · ESC release

Why it matters to you: demand ischemia in an elderly septic or GI-bleeding patient is one of the highest-volume documentation decisions you make, and the reason the societies gave for the change is exactly your complaint — the numbered types were applied inconsistently. "Secondary MI" with the precipitant named is clearer than "type 2 MI" ever was, and the ICD-11 codes mean coding and CDI will eventually be pulling for that phrasing. The sex-specific thresholds are the quieter change: your default troponin cutoff has been doing a woman's rule-in and a man's rule-out with the same number.

Worth raising: ask whoever owns your chest-pain order set and CDI queries when the local troponin reference ranges and MI-type language get updated — this is the kind of change that sits in a journal for eighteen months before anyone touches the EHR.

Guideline · Heart Failure

2026 ESC heart failure guidelines: HFmrEF deleted, "acute HF" becomes "decompensated HF," staging goes A through D

The new ESC HF guideline collapses three ejection-fraction phenotypes back into two: HFrEF is now any LVEF under 50% (absorbing the old 41–49% mildly-reduced band) and HFpEF is LVEF 50% or above. The term "acute heart failure" is replaced by "decompensated heart failure" on the grounds that most of these patients don't decompensate suddenly — function drifts until compensation fails. A four-stage framework (A at-risk, B pre-HF with structural abnormality, C symptomatic, D advanced) now runs alongside the phenotypes. Cardiac rehabilitation and a first joint ESC/ERA cardiovascular-plus-CKD guideline landed the same week. HCPLive · Cardiovascular Business

Why it matters to you: the EF 41–49% patient has been the most annoying admission in your service line — not clearly a quadruple-therapy patient, not clearly a diuresis-and-discharge patient. Europe just resolved the ambiguity in the direction of treating them like HFrEF. US guidelines haven't followed, so for now you'll see both vocabularies in the same chart, and the mismatch will show up in transfers and in cardiology consults trained abroad. The "decompensated" relabel is more than semantics: it reframes the admission as a failure of a slow process, which is the framing that supports asking what changed at home three weeks ago.

Talking point: good agenda item for the next group meeting — which EF bucket your order sets and readmission metrics key off, and whether an EF of 45% currently routes to the HFrEF pathway at your shop.

B · The Debate

After a brain bleed, should a patient with atrial fibrillation ever go back on anticoagulation?

ENRICH-AF reported Saturday at ESC — the largest randomized trial ever run in this population — and landed on the opposite side of PRESTIGE-AF, the trial that reported eighteen months ago. Both are randomized, both are European-led, both enrolled ICH survivors with AF, and they disagree about what to do Monday morning. An ACC clinician poll in June already showed the field split down the middle before either trial settled anything.

The case for restarting

Roland Veltkamp, Imperial College London — PRESTIGE-AF, The Lancet

The thing that kills these patients over the following years is not usually another bleed — it's the stroke you didn't prevent. PRESTIGE-AF, run across 75 hospitals in six European countries, is the first completed phase 3 trial to show a significant reduction in ischemic stroke with a DOAC in ICH survivors with AF, and the size of that reduction was not marginal. Recurrent intracerebral hemorrhage did rise sharply, but ischemic strokes in this group are common, disabling and preventable, while the population at real re-bleed risk is identifiable in advance by hemorrhage location and imaging markers. The argument is not that everyone restarts — it's that a blanket refusal to anticoagulate an 80-year-old with AF and a deep, hypertensive bleed trades a treatable risk for an untreatable one. TCTMD coverage

The case against

Ashkan Shoamanesh, McMaster University — ENRICH-AF, ESC Congress 2026

When you finally run the trial big enough to answer the question, the net benefit isn't there. ENRICH-AF randomized 948 patients (mean age 77) at 174 sites in 20 countries and followed them 28 months: edoxaban did not reduce the primary endpoint of stroke or systemic embolism (11.8% vs 12.8%; HR 0.88, 95% CI 0.61–1.26). Ischemic strokes and MIs did fall — and were offset by a nearly three-fold excess of hemorrhagic stroke. Major bleeding more than doubled, 11.6% vs 5.2% (HR 2.23, 95% CI 1.39–3.59). And the trial's own safety board stopped enrolling lobar hemorrhage and convexity subarachnoid patients in 2023 for excess re-bleeding, meaning the population left in the analysis was the favorable one. Shoamanesh's stated conclusion: the findings do not support edoxaban in unselected patients with AF after intracranial hemorrhage.

Where it might land: both camps effectively agree that hemorrhage location is the hinge — lobar and amyloid-pattern bleeds off the table, deep hypertensive bleeds arguable — so the next fight is over whether left atrial appendage occlusion becomes the default third option for the patients neither trial could safely anticoagulate.

C · On My Radar

SINGLE-AF gives the low-score AF patient an answer. First randomized trial in AF patients at intermediate stroke risk: apixaban or rivaroxaban cut the composite of stroke, systemic embolism, major bleeding and cardiovascular death by 69% at 24 months (0.5% vs 1.5%; HR 0.31, 95% CI 0.10–0.94), with no excess major bleeding (0.3% vs 0.5%). Presented at ESC, published in NEJM. Relevant to every incidental AF you pick up on telemetry in someone with a CHA₂DS₂-VASc of 1. HCPLive · TCTMD

Update — COVID still climbing into September. CDC's Rt modeling as of Aug 26 has infections growing or likely growing in 48 states, none declining, two flat; national and regional activity increasing, rhinovirus/enterovirus rising alongside. Overall acute respiratory illness remains low, so the census pressure is still ahead of you rather than on you. CDC

Mets 6, Astros 2 — and Juan Soto is back. Soto activated off the IL Saturday for the final stretch and the Mets took the opener at Citi Field. First good news out of that clubhouse in a week after dropping three straight. ESPN

Update — Puerto Rico's taps: it isn't only the drought. Reporting Friday put the structural number on it — AAA loses or fails to bill roughly 65% of the water it produces, and the immediate trigger for San Juan's rationing was a series of ruptures in the Superaqueduct, the 72-inch line carrying potable water 50 miles along the north coast. Rainfall deficits may run below normal into January; 180,000+ customers remain on 48-hour rotating shutoffs. CNN · NPR

Cuba opens the school year next week anyway. Roughly 1.4 million children return in early September despite uniform and supply shortages, transport disruption and falling teacher numbers — against a backdrop of six national grid collapses so far in 2026 and electricity down to a few hours a day in many municipalities. Reuters via US News · CBC

Iran digs in on sanctions. Tehran said Saturday it will stand firm against what it calls unjust US measures, as the IRGC continued asserting control over the Strait of Hormuz and Washington pressed "Operation Economic Outcast," the roughly 60-entity sanctions wave announced Aug 24. No military escalation reported. Al Jazeera

Golf tech: nothing new in 48 hours — 29th straight day. Pipeline unchanged: Shot Scope LM1, Par Breaker Swing Pulse X10, Garmin G82, Rapsodo's native PC sim software still slated for later this year.

D · Trends to Watch

Cardiology is finally enrolling the patients you actually admit. STAREE (over-70s, no CVD), ENRICH-AF (mean age 77, prior brain bleed), SINGLE-AF (CHA₂DS₂-VASc scores everyone used to argue about) — these are precisely the groups the landmark trials of the 2000s and 2010s excluded by design. The exclusion criteria of one decade are becoming the trials of the next, and the answers are not uniformly reassuring.

Event reduction and functional outcome are separating. STAREE cuts major cardiovascular events by 30% and leaves disability-free survival flat. As geriatric trials adopt function as a co-primary endpoint rather than a secondary, expect more results shaped like this — real benefit on the count, no benefit on the thing the patient came in worried about. Consent and goals-of-care conversations get harder and more honest at the same time.

Cardiac taxonomy is collapsing toward mechanism. Numbered MI types gone; the mildly-reduced EF band gone; "acute" HF renamed for how it actually behaves. Three separate documents in one week moved from arbitrary numeric bins toward categories that map onto a decision. Good for teaching, temporarily bad for chart consistency while US and European vocabularies diverge.

E · Ideas & Opportunities

Ask pharmacy for a list of your over-75 admissions on a statin with no CAD, stroke, or diabetes. STAREE gives you the numbers to have that conversation on a discharge call instead of punting it. You'll probably be surprised how many are on high-intensity dosing they were started on in their sixties.

Find out who owns MI-type language locally. With "type 2 MI" formally retired and ICD-11 codes attached to the new categories, there's a window to get "secondary MI due to [precipitant]" into templates before coding starts querying you about it. Same conversation covers sex-specific troponin thresholds.

Post-nights watch: Coyote vs. Acme is in wide release at 96% on the Tomatometer — the Warner Bros. write-off that got rescued and finally shipped. Low effort, high payoff for a 9am wind-down.