The Curbsiders Internal Medicine Podcast #523 Hotcakes: Left Atrial Appendage Closure vs AC for Afib, Apixaban vs Rivaroxaban for VTE, Intensive LDL Targeting, GLP1s and Substance Use Disorders, and more
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Apr 27, 2026 
Shani Herzig, a practicing hospitalist and pharmacoepidemiologist, breaks down recent trials and study design quirks. They tackle left atrial appendage closure versus anticoagulation, apixaban versus rivaroxaban for VTE, and intensive LDL targeting. They also explore GLP-1s in substance use disorders, a new oral GLP-1 approval, e-cigarette cancer signals, and early-morning blood draw effects on sleep.
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How Trial Design Favored Device Noninferiority
- High crossover and outcome selection biased CHAMPION AF toward non-inferiority by making groups look more similar.
- Inclusion of cardiovascular death and exclusion of periprocedural bleeding diluted differences and ignored procedural harms like pericardial effusion.
Tell Patients Anticoagulation Still Preferred Over LAAO
- For patients without contraindications, continue NOAC anticoagulation rather than switching to Watchman-style devices.
- Explain devices still require early antiplatelet/anticoagulant regimens and often lifelong aspirin, so stroke prevention may be worse.
COBRA Population Was Highly Selected
- COBRA was well-executed but enrolled a selected population (≈30% of screened), excluding severe obesity, active cancer, and advanced cirrhosis.
- Generalizability to broader VTE patients may be limited despite robust bleeding signal.