A Different Kind of Restraint: A Conversation with Dr Sukh Nijjer
Reflections from a Year in Cardiology
Some conversations focus on what is new. Others attend to what no longer fits as neatly as it once did.
The episode 151 of Parallax belongs to the latter. Rather than cataloguing breakthroughs, the episode traces how certainty has softened across several areas of cardiovascular practice, and how clinical judgement is increasingly being asked to carry more weight.
What emerges is not a single conclusion, but a pattern of recalibration. Metrics, adherence, innovation, and even the definition of necessity itself come into question.
When Old Metrics Begin to Strain
Few examples illustrate this more clearly than the use of beta blockers after myocardial infarction. For decades, beta blockers have been treated as foundational therapy. In the UK, their prescription remains a mandated quality metric, audited nationally.
Yet the clinical context has changed entirely. Early reperfusion, complete revascularisation, preserved left ventricular function, and door to balloon times measured in hours define a fundamentally different patient population.
“Heart attack treatment is very different now.”
This year, two major trials presented at the European Society of Cardiology examined relatively well patients with preserved systolic function following myocardial infarction. In both REBOOT-SYNC and DanBlock, routine long term beta blocker therapy did not reduce major clinical endpoints.
The unease raised by these findings is not statistical, but cultural. In practice, clinicians continue to feel pressure to prescribe in order to satisfy metrics, even when individual benefit is unclear.
“Adding a low dose beta blocker is probably only making the doctor feel better by hitting the quality metric rather than helping anything to do with the patient.”
The conversation does not argue for abandoning beta blockers. It argues for abandoning universality. In the well patient with preserved systolic function, the obligation to prescribe is no longer self evident.
Adherence as a Clinical Reality
Heart failure shifts the focus away from efficacy and towards something more fundamental. Adherence.
Despite advances in pharmacotherapy, medication adherence remains fragile, even among motivated patients.
“In this motivated group of patients, only 30% of the time people were opening the device to take a pill out.”
The POLY-HF study explored whether simplification rather than escalation could improve outcomes. By consolidating core therapies into a fixed dose poly pill, adherence improved and left ventricular function increased.
The population studied is central to the lesson. Many participants were socioeconomically vulnerable, uninsured, or experiencing housing and food insecurity.
“We can deliver high quality heart failure management in a really limited way, just two pills, and get big gains.”
The implication is profound. High quality care does not always require complexity. In constrained systems, coherence may matter more than intensity.
Atrial Fibrillation and the Question of Stopping
Atrial fibrillation introduces a different kind of uncertainty, one increasingly voiced by patients. After successful ablation, can anticoagulation be stopped.
The OCEAN study addressed this directly, randomising patients with no recurrent atrial fibrillation to either continued anticoagulation or aspirin.
“This is exactly the question that we get asked all the time.”
The study was stopped early for futility, with no clear benefit to continued anticoagulation and higher bleeding rates in the anticoagulated arm.
The conclusions are necessarily cautious. Event rates were low. Absolute differences were modest. Yet the study provides reassurance.
“This gives a little bit of reassurance that people don’t need to panic.”
Practice has not shifted wholesale, but the conversation has. Stopping anticoagulation is no longer indefensible in carefully selected patients.
Closure AF and the Limits of Intervention
If OCEAN invites cautious openness, CLOSURE-AF reinforces restraint.
Left atrial appendage closure has been widely adopted in some settings, yet the ClOSURE-AF trial failed to demonstrate non inferiority compared with medical therapy.
“I personally have not been a strong proponent of left atrial appendage closure.”
Clinical experience reinforces the trial findings. Many patients continue anticoagulation despite device implantation, while others develop device related thrombus or residual leaks.
“You sort of end up being on the oral anticoagulant anyway.”
At the same time, advances in atrial fibrillation ablation offer alternative paths.
“Our AF ablation techniques have got better.”
In this light, appendage closure appears increasingly as a niche intervention, rather than a broadly applicable solution.
Innovation, Held Carefully
Interventional cardiology remains a field defined by innovation. Bio adaptable stents, drug coated balloons, and new revascularisation strategies featured prominently this year.
The INFINITY-Swedeheart study demonstrated promising results with a bio adaptable stent that allows late vessel expansion.
Yet the response remains measured.
“We should step slowly rather than rushing headlong into something and putting these devices everywhere.”
Past experience with bioresorbable scaffolds looms large.
“Our approach with bioresorbable scaffolds wasn’t good and the outcomes were negative.”
Innovation, here, is welcomed but not rushed.
Prevention and the Weight of Accumulation
The discussion closes with prevention, where enthusiasm and unease coexist.
GLP-1 receptor agonists have become among the most requested therapies in cardiology clinics.
“The number one drug people ask me about now are the GLP-1 agonists.”
Recent trials demonstrate cardiovascular benefit, yet the cumulative burden of therapy is increasingly difficult to ignore.
“At what point do we stop adding more to the armamentarium for our patients?”
The underlying drivers of disease remain societal.
“Our towns and cities encourage sedentary lifestyles.”
Medication mitigates risk, but does not resolve the environment that produces it.
What Stays With You
What lingers after this conversation is not a single trial or technology.
It is a posture.
Careful with devices.
Selective with prescriptions.
Attentive to adherence.
Wary of certainty that arrives too easily.
“It’s not about rushing ahead based on the vibe that we think this is better.”
Like other Parallax conversations this year, this episode does not urge forward motion.
It pauses.
And in doing so, it asks a quieter, more difficult question.
How do we decide what is truly necessary.
🎧 Episode 151 of Parallax is produced by Radcliffe Cardiology in association with MakeADent.org.