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Hi, everyone.

This is John Mandrola from the Heart.org Medscape Cardiology, and this is this week in cardiology for March 20th,

2026. This week, some listener feedback, the huge publication of the closure AF trial, of left atrial

appendage closure versus best medical therapy, a preview of the Champion AF study, and the controversial

ACC-A-J lipid treatment guidelines. Today I have kind of a longer discussion on fewer topics.

Left atrial appendage closure and lipid treatment are so important and so common,

I felt like we needed more detailed discussion

on these topics.

First, though, some listener feedback.

On the matter of the Cobra trial of Apixaband

versus River Oxiban for VTE and PE,

in which Apixaband had a 54% statistically significantly lower rate of major bleeding. Clinical

pharmacist Lorenz van der Linden writes from Lundon, Belgium, to remind me that two drugs' initial

regimens were not actually loading doses. Loading dose implies filling an apparent distribution volume

to reach the target concentration faster.

Instead, the higher doses of these two DOACs, Apixaban and Riveroxiban, were actually lead-in doses

to provide more intensive anticoagulation, which is sort of analogous to the therapeutic doses

of parental anticoagulation such as enoxaparin or heparin that was used before warfarin.

These higher lead-in doses allows the body to

...