The written exam marks the current Australian answer, and the answer moves a little most weeks. This is the first of the weekly notes that sit between the monthly round-ups: what was published between 2 and 8 November 2026 that an FRACP candidate should know, what the previous answer was, and what the answer is now. The PBS schedule changes only on the first of the month, and the one Australian and New Zealand guidance document this week (an intensive care consensus statement, below) sits at the edge of the adult medicine syllabus, so this week's main items are trials. Each is overseas, and each either changes a position an Australian guideline currently holds or settles a question examiners already ask.
1. Moderate aortic stenosis with at-risk features: TAVR beat surveillance (PROGRESS)
What changed. The PROGRESS trial (New England Journal of Medicine, 2 November 2026) randomised 744 patients with moderate aortic stenosis (mean valve area 1.2 cm2, mean peak velocity 3.3 m per second) and at least one at-risk feature, meaning a symptom or a structural or functional abnormality linked to faster progression, to transfemoral TAVR with a balloon-expandable valve or to clinical surveillance. Mean age was 78 and 45.6 per cent were at low surgical risk. At two years the composite of death from any cause or a heart failure event occurred in 16.7 per cent of the TAVR group and 23.9 per cent of the surveillance group (risk difference minus 7.2 percentage points, P equals 0.02 for superiority). The difference came from heart failure events (10.8 versus 19.0 per cent); death from any cause was 8.4 versus 7.3 per cent. Edwards Lifesciences funded the trial.
What it means for the exam. The current answer, in the ESC and EACTS and the ACC and AHA valve guidelines that Australian practice follows, is that moderate aortic stenosis is watched with echocardiography every one to two years and intervention waits for severe disease or a surgical indication. PROGRESS is the first randomised evidence that intervening earlier helps a selected group, and it will push the guidelines. For now the safe written answer stays surveillance for moderate stenosis, but a question that names at-risk features (symptoms, reduced ejection fraction, raised natriuretic peptide, rapid progression) now has a trial behind the "consider early valve replacement" option, and a long case candidate who knows PROGRESS and names it as emerging evidence, not yet guideline, is where the mark sits. Our Aortic Valve Disease course teaches surveillance for moderate stenosis and that intervention for moderate stenosis is unproven; it will carry the trial.
2. Severe hypertriglyceridaemia: plozasiran lowered triglycerides by about 80 per cent and cut pancreatitis (SHASTA-3 and SHASTA-4)
What changed. Two identical double-blind trials (New England Journal of Medicine, 5 November 2026) randomised 757 adults with severe hypertriglyceridaemia 2 to 1 to plozasiran 25 mg, a small interfering RNA against APOC3 messenger RNA, or placebo, given at baseline and at months 3, 6 and 9. At month 12 the median triglyceride level was 79 and 81 per cent below baseline in the two trials, a placebo-adjusted difference of minus 45 and minus 47 percentage points. A triglyceride level under 5.6 mmol per litre at 12 months was reached by 91 and 93 per cent on plozasiran against 51 and 50 per cent on placebo. Pooled, acute pancreatitis occurred at 1 per 100 patient-years with plozasiran and 5 per 100 patient-years with placebo (rate ratio 0.22, P equals 0.008). Adverse events were 73 per cent in both groups. Arrowhead Pharmaceuticals funded the trials.
What it means for the exam. The previous answer for severe hypertriglyceridaemia was drivers first (alcohol, glucose, drugs), then a fibrate, with fish oil and niacin as weak adjuncts. The APOC3 agents changed that: olezarsen, an antisense oligonucleotide, reduced pancreatitis in severe hypertriglyceridaemia in the CORE trials earlier in 2026, and SHASTA-3 and 4 now do the same with plozasiran, the first small interfering RNA against APOC3. In Australia plozasiran is not in the PBS medicine index as at November 2026 and its TGA status could not be checked from here, so the Australian answer is unchanged in practice; a question about the mechanism (APOC3 silencing, the target olezarsen and the familial chylomicronaemia trials established) or about which drug class has randomised evidence against pancreatitis now has a specific answer. Our Lipid Disorders course covers severe hypertriglyceridaemia and the APOC3 agents at principle level.
3. Stable coronary disease: no survival difference at 11 years (ISCHEMIA-EXTEND)
What changed. The ISCHEMIA-EXTEND long-term follow-up (JAMA, 7 November 2026) followed the 5,179 ISCHEMIA participants (stable coronary disease, moderate or severe ischaemia, ejection fraction 35 per cent or more, no left main disease) to a median of 9 years. All-cause mortality at 11 years was 25.8 per cent with an initial invasive strategy and 26.9 per cent with an initial conservative strategy (difference minus 1.0 percentage point, 95 per cent confidence interval minus 4.2 to 2.1; adjusted hazard ratio 0.97). The Bayesian probability of more than a one percentage point survival benefit from the invasive strategy was 18 per cent.
What it means for the exam. The 2023 interim ISCHEMIA-EXTEND report had shown fewer cardiovascular deaths in the invasive arm, balanced by more non-cardiovascular deaths, and some candidates learned "invasive reduces cardiovascular death". The final answer is the one the original trial gave: in stable disease on good medical therapy, routine revascularisation does not improve survival; it treats angina and is for high-risk anatomy and failed medical therapy. Our Stable Ischaemic Heart Disease and Landmark Trials courses already teach this and gain the long-term figures.
4. Kidney failure in the frail old: preparing for conservative management matched preparing for dialysis on quality-adjusted life (Prepare for Kidney Care)
What changed. Prepare for Kidney Care (Lancet, 4 November 2026) was a pragmatic randomised trial in 31 UK kidney centres. Eligible patients had an eGFR under 15 and were either 80 or older, or 65 to 79 with a WHO performance status of at least 3 or a Davies comorbidity score of at least 2. 445 patients (median age 82) were randomised to prepare for responsive management, a protocolised conservative kidney management pathway, or to prepare for dialysis. Over a mean 4.5 years of follow-up, quality-adjusted life-years were 1.354 in the conservative arm and 1.472 in the dialysis arm (adjusted mean difference minus 0.147, 95 per cent confidence interval minus 0.350 to 0.056, P equals 0.16). Hospital admission rates were similar; dialysis access complications were lower in the conservative arm (incidence rate ratio 0.41). Deaths were 69 per cent in the conservative arm and 63 per cent in the dialysis arm over the follow-up.
What it means for the exam. Conservative kidney management has been taught as a reasonable choice for older, frail patients with high comorbidity, on observational data suggesting little survival gain from dialysis after about 75 with comorbidity. This is the first randomised comparison, and it did not show a quality-adjusted life advantage for either pathway. In a long case with an octogenarian or a frail patient approaching kidney failure, the answer is now a shared decision with a randomised trial behind it, and the candidate who can say "no demonstrated QALY difference and fewer access complications" shows currency. Our Renal Replacement Therapy and Chronic Kidney Disease courses teach conservative management as an option and will cite the trial.
5. CT angiography planning was non-inferior to intravascular ultrasound guidance for PCI (P4)
What changed. The P4 trial (New England Journal of Medicine, 1 November 2026) randomised 1,105 patients with an indication for revascularisation, a stenosis over 70 per cent and a CT-derived fractional flow reserve of 0.80 or less to a CT angiography-guided or an intravascular ultrasound-guided PCI strategy. Target-vessel failure at 12 months was 4.1 per cent with CT guidance and 4.6 per cent with intravascular ultrasound (risk difference minus 0.42 percentage points; P under 0.001 for non-inferiority against a 4.5 point margin). GE HealthCare and Heartflow funded it.
What it means for the exam. Intravascular imaging-guided PCI improves outcomes over angiography alone and is the current guideline position for complex lesions. P4 says pre-procedural CT angiography can plan the stent to the same clinical standard as intravascular ultrasound in this population. It is a procedural detail for the written exam, but it fits the growing role of CT angiography in Australian practice: the written answer "CT coronary angiography is for diagnosis in low to intermediate pre-test probability" now extends to planning.
6. Cardiogenic shock after infarction: intravenous cangrelor inhibited platelets reliably but did not prove non-inferior on outcomes (DAPT-SHOCK-AMI)
What changed. DAPT-SHOCK-AMI (Lancet, 7 November 2026) randomised 605 patients with acute myocardial infarction complicated by cardiogenic shock in five European countries to intravenous cangrelor or crushed ticagrelor 180 mg. A platelet reactivity index under 50 per cent at the end of primary PCI was reached by 100 per cent of the cangrelor patients tested (56 of 56) and 22 per cent of the ticagrelor patients tested (15 of 68). The 30-day composite of death, infarction or ischaemic stroke was 38 per cent with cangrelor and 41 per cent with ticagrelor; non-inferiority against a one percentage point margin was not shown (difference minus 4 points, 90 per cent confidence interval minus 10 to 3). Major bleeding was 6 versus 5 per cent.
What it means for the exam. The teaching point is the pharmacology: oral P2Y12 inhibitors are absorbed poorly in shock, which is why crushed ticagrelor and intravenous agents are discussed. Cangrelor achieved the platelet target in every patient tested, crushed ticagrelor rarely did, yet the clinical outcome did not separate at 30 days. The Australian answer is unchanged (no current PBS listing was found for cangrelor); a question on why platelet inhibition is unreliable in cardiogenic shock now has its trial.
Also published this week
- IRIS-MAIN registry (Lancet, 3 November): 5,379 Asian patients with left main disease treated with stents or bypass; 10-year all-cause mortality 24.0 versus 22.9 per cent with no detectable difference. Observational, and it does not move the guideline position (bypass for complex left main disease, heart team for the rest).
- GINA 2026 strategy report executive summary (European Respiratory Journal, 5 November): the summary names expanded anti-inflammatory reliever options, revised severe asthma and biologic selection guidance and updated acute asthma management as the key 2026 changes. The full report could not be opened from here; the Australian Asthma Handbook, not GINA, is the exam reference, and it already holds the anti-inflammatory reliever position.
- American Thoracic Society guideline on inhaled corticosteroid reliever therapy (3 November): strong recommendations for as-needed ICS-formoterol or ICS-SABA over SABA alone at steps 1 and 2, and for ICS-formoterol maintenance-and-reliever therapy over scheduled ICS-LABA plus as-needed SABA at steps 3 to 5. It aligns the US position with the Australian one.
- ANZICS and CICM consensus statement on percutaneous dilatational tracheostomy (Anaesthesia and Intensive Care, 5 November): Australian and New Zealand guidance for adult intensive care; relevant to the intensive care content of the written exam at principle level.
Left out, and why
- The TGA safety alerts page and the ATAGI statements page did not respond from this environment, so any safety advisory or immunisation statement from this week is not here; the monthly round-up checks them again.
- Consensus, the literature search tool, had no searches left for November; the sweep used PubMed by journal and specialty, so a guideline published outside the indexed journals this week could have been missed.
- The PBS schedule changed on 1 November and those changes are in the November notes; the only PBS news this week was the publication of the PBAC stakeholder meeting outcome statement for the rapid review of relapsing-remitting multiple sclerosis medicines (4 November), a process step rather than a listing.
The month's page at /guideline-updates/2026-11 will gather these weekly notes with the November PBS changes once it is drafted. The courses, 352 of them, with 11,100+ questions, are where the detail and the practice live. Next week's note follows the same shape.