I know one is ill-advised to use the term “second tier,” but with about 150 journals with cardiology titles, “second tier” is not an insult. It strikes me that much of what we see in the most prestigious journals, we have already heard about from news media. Some of those studies with high enough priority to make it to one of those journals are years in the making, are investigating things with marginal differences (otherwise there would not be equipoise), have required massive funding (mostly from industry), rarely are surprising and, therefore, may not change the way we practice.