ESC Congress 2026 · Munich · Day 2

One Win, Three Reality Checks

Saturday, 29 August 2026 — what mattered for practising cardiologists

The day's clear winner was STAREE, which finally gives us randomised evidence for statins in primary prevention after age 70. Among 9,971 community-dwelling adults free of vascular disease, diabetes and dementia, atorvastatin 40 mg cut major cardiovascular events by roughly a third (6.0% vs 8.3%; HR 0.70). The catch: the co-primary endpoint of disability-free survival was unchanged, and muscle, hepatic and dysglycaemic adverse events were more common. So the drug prevents infarcts and strokes in older people — it does not, on this evidence, buy them independent years.

The other three Hot Lines all landed negative — and each was a widely held assumption.

In LIBREXIA-ACS (14,194 patients), the oral factor XIa inhibitor milvexian added to antiplatelet therapy after acute coronary syndrome did nothing to ischaemic risk (5.4% vs 5.1%; HR 1.05), though it did keep its clean bleeding signature. Meanwhile AMUNDSEN showed that giving evolocumab before primary PCI doubles the proportion reaching LDL-C goal at one year (82% vs 40%) — but with no significant difference in death or unplanned cardiovascular hospitalisation in the intention-to-treat analysis. Surrogate met, outcome not yet.

Most provocative for anyone running a chest-pain pathway: PRESC1SE-MI, a stepped-wedge trial across 67,624 emergency presentations in 11 countries, found the ESC 0/1-hour high-sensitivity troponin algorithm to be reassuringly safe (30-day death or type 1 MI 1.1% vs 1.2%, non-inferior) yet completely neutral on emergency department length of stay — a median of 309 minutes in both arms. Faster biochemistry does not equal faster discharge; the bottleneck is the workflow around the assay, not the assay.

Key message

Day 2 rewarded an old, cheap drug in an undertreated age group — and reminded us that a better biomarker, a cleaner anticoagulant, or a lower LDL-C does not automatically become a better outcome.

Learn more

• STAREE — atorvastatin, cardiovascular events and disability-free survival in older adults (NEJM)
• STAREE trial summary (American College of Cardiology)
• LIBREXIA-ACS — milvexian after recent acute coronary syndrome
• AMUNDSEN — evolocumab before PCI for acute myocardial infarction (JAMA)
• PRESC1SE-MI — ESC 0/1-hour algorithm and emergency department length of stay
• Full ESC Congress 2026 Hot Line programme

Trial data as presented at ESC Congress 2026, Munich, 29 August 2026. For educational use; verify against the primary publications before changing practice.