European Heart Journal (2014) 35, 3145–3151 doi:10.1093/eurheartj/ehu393
2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism New features of the 2014 Guidelines are discussed by Professor Stavros Konstantinides, Task Force chairman The most clinically relevant new aspects of the 2014 version of the ESC Guidelines (published in Issue 43 of this volume) when compared with the previous version published in 2008 relate to:
More specifically, (1) In vitro fertilization increases the risk of pregnancy-associated VTE up to 7-fold. Blood transfusion and erythropoiesisstimulating agents are also associated with an increased risk of VTE. In children, PE is usually associated with deep vein thrombosis (DVT) and is rarely unprovoked. Serious chronic medical conditions and central venous lines are considered to be likely triggers of PE. (2) The combination of findings evaluated by the use of prediction rules allows patients with suspected PE to be classified into distinct categories of clinical or pre-test probability. Recently, both the Wells and the revised Geneva rules were simplified in an attempt to increase their adoption into clinical practice. Whichever version is used, the proportion of patients with confirmed PE can be expected to be 10% in the low-probability category, 30% in the moderate-probability category, and 65% in the high-clinical probability category. When the two-level classification is used, the proportion of patients with confirmed PE in the PE-unlikely category is 12%.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
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(1) Recently identified predisposing factors for venous thromboembolism (VTE) (2) Simplification of clinical prediction rules (3) Age-adjusted D-dimer cut-offs (4) Sub-segmental pulmonary embolism (5) Incidental, clinically unsuspected pulmonary embolism (6) Advanced risk stratification of intermediate-risk pulmonary embolism (PE) (7) Treatment and secondary prophylaxis of VTE with the new direct oral anticoagulants (NOACs) (8) Efficacy and safety of reperfusion treatment for patients at intermediate risk (9) Early discharge and home (outpatient) treatment of PE (10) Current diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) (11) Formal recommendations for the management of PE in pregnancy and of pulmonary embolism in patients with cancer.
(3) The specificity of D-dimer in suspected PE decreases steadily with age. In a multicentre, prospective management study, using an age-adjusted (age × 10 mg/L, if .50 years) instead of the ‘standard’ 500 mg/L cut-off increased the number of patients in whom PE could be excluded from 6.4 to 29.7%, without any additional false-negative findings. (4) Computed tomographic (CT) angiography showing a segmental or more proximal thrombus confirms PE. On the other hand, the clinical significance of isolated sub-segmental PE on CT angiography is questionable and further testing may be considered. In a patient with isolated sub-segmental PE and no proximal DVT, the decision on whether to treat should be made on an individual basis, taking into account the clinical probability and the bleeding risk. (5) Some experts believe that patients with incidental (unsuspected) PE on CT should be treated, especially if they have cancer and a proximal clot, but solid evidence is lacking. (6) Initial risk stratification of suspected or confirmed PE—based on the presence of shock or persistent hypotension—is recommended to identify patients at high risk of early mortality. In patients not at high risk, use of a validated clinical risk prediction score, preferably the pulmonary embolism severity index (PESI) or its simplified version (sPESI), should be considered to distinguish between low- and intermediate-risk PE. Normotensive patients in PESI Class ≥III or sPESI of ≥1 are considered to constitute an intermediate-risk group. Within this category, further risk assessment should be considered. Patients who display evidence of both RV dysfunction (by echocardiography or CT angiography) and elevated cardiac biomarker levels in the circulation (particularly a positive cardiac troponin test) should be classified into an intermediate-high-risk category. On the other hand, patients in whom the RV is normal on echocardiography or CT angiography, and/or have normal cardiac biomarker levels, belong to an intermediate- to low-risk group. (7) The results of the trials using NOACs in the treatment of VTE indicate that these agents are non-inferior (in terms of efficacy) and possibly safer (particularly in terms of major bleeding) than the standard heparin/vitamin K antagonist (VKA) regimen. The results of the trials using NOACs in the extended treatment of VTE are in line with those of the studies that tested these agents in the acute-phase treatment and standard duration of anticoagulation after PE or VTE. Therefore, NOACs are recommended as
3146 an alternative to the combination of parenteral anticoagulation with a VKA (for rivaroxaban or apixaban), or as an alternative to VKA treatment following acute-phase parenteral anticoagulation (for dabigatran or edoxaban). Rivaroxaban, dabigatran, and apixaban are approved for treatment of VTE in the European Union; edoxaban is currently under regulatory review. NOACs are not recommended in patients with severe renal impairment. (8) Routine use of primary systemic thrombolysis is not recommended in patients without shock or hypotension, but close monitoring is recommended in patients with intermediate- to high-risk PE to permit early detection of haemodynamic decompensation. Thrombolytic therapy should be considered for patients with intermediate- to high-risk PE and clinical signs of haemodynamic decompensation. Surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative, ‘rescue’ procedures for patients with intermediate- to high-risk PE, in whom haemodynamic decompensation appears imminent and the anticipated bleeding risk under systemic thrombolysis is high. (9) Patients with acute, low-risk PE should be considered for early discharge and continuation of treatment at home if proper outpatient care and anticoagulant treatment can be provided.
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(10) It is recommended that, in all patients with CTEPH, the assessment of operability and decisions regarding other treatment strategies be made by a multidisciplinary team of experts. Riociguat is recommended in symptomatic patients who have been classified as having inoperable CTEPH by a CTEPH team including at least one experienced pulmonary endarterectomy (PEA) surgeon, or have persistent/recurrent CTEPH after surgical treatment. (11) Suspicion of PE in pregnancy warrants formal diagnostic assessment with validated methods. Venous compression ultrasonography may be considered in order to avoid unnecessary irradiation in pregnant patients, as a diagnosis of proximal DVT confirms PE. A weight-adjusted dose of LMWH is the recommended therapy during pregnancy in patients without shock or hypotension. For patients with PE and cancer, weightadjusted subcutaneous LMWH should be considered for the first 3–6 months; extended anticoagulation (beyond the first 3–6 months) should be considered for an indefinite period or until the cancer is cured. Stavros V. Konstantinides, MD, PhD, FESC ESC Task Force Chairman [email protected]
(1) Assessment of haemodynamic stability of the patient and clinical probability of pulmonary embolism (PE) is the basis of all diagnostic strategies. (2) Appropriate use of D-dimer testing may reduce the need for unnecessary imaging and irradiation. (3) While computed tomographic angiography plays a key role in diagnostic algorithms, ventilation-perfusion (V/Q), compression venous ultrasonography, and emergency echocardiography may be helpful in management decisions. (4) Clinical assessment may identify patients at high risk (with shock or hypotension) requiring primary revascularization therapy, and patients at low risk of early death despite confirmed PE (Pulmonary Embolism Severity Index classes I or II) who can be considered for early discharge if appropriately anti-coagulated. (5) Among the remaining patients, those with signs of both right-ventricular overload and positive humoral biomarkers (troponin, BNP) represent an intermediate- to high-risk group which should be monitored, as they may require rescue reperfusion therapy if clinical signs of haemodynamic decompensation appear. (6) Primary reperfusion treatment, particularly systemic thrombolysis, is the treatment of choice for patients with high-risk PE. (7) Surgical pulmonary embolectomy and percutaneous catheter-directed treatment are alternative methods of primary and rescue reperfusion treatment. (8) For most cases of acute PE without haemodynamic compromise, low-molecular-weight heparin or fondaparinux is the initial treatment of choice. Unfractionated heparin should be used in haemodynamically unstable patients and those with severe renal dysfunction. (9) The non-vitamin-K-dependent oral anticoagulants (NOACs; direct inhibitors of factor Xa or thrombin) are non-inferior in terms of efficacy and possibly safer, particularly in terms of major bleeding, than the standard anticoagulation regimen consisting of heparin followed by a vitamin K antagonist. (10) Management of PE in patients with cancer and in pregnancy, duration of anti-coagulation after initial episode, and management of patients with persisting symptoms and suspected/confirmed chronic thromboembolic pulmonary hypertension after PE all require specific considerations and may need to follow separate recommendations—see guidelines. These Guidelines were published in Issue 43 of this volume. For more information, see http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/essential-message-slideset.aspx Stavros Konstantinides: MD and Adam Torbiki, MD
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The ‘Ten Commandments’ for ESC guidelines on pulmonary embolism
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European Society of Cardiology European Affairs: bringing science to policy-makers Frans Van de Werf, Chairman of the European Society of Cardiology European Affairs Committee since 2010, explains what European Affairs is all about and why it is key for a medical society to engage in European Union policy-making
(1) Promote the interests of the ESC and its constituent bodies at the level of EU institutions (2) Secure a European environment favourable for tackling cardiovascular disease (3) Ensure that cardiovascular health is considered a key priority by decision makers across Europe To achieve these objectives, ESC European Affairs follow policy activities and devise initiatives in the following areas: Prevention: Activities aim at stimulating the development of national strategies to combat heart disease by providing practical tools to act both at population and individual levels.
Research: The European Affairs Committee strives to improve the standards of cardiovascular research in Europe through the identification and promotion of research needs and priorities. Regulatory affairs: The goal is to establish an open dialogue and exchange with European authorities on regulatory aspects. Activities focus mainly on drugs and medical devices. Registries: The European Affairs Committee is dedicated to ensuring political support for the development of comparable cardiovascular data in the European Union. Groups: The ESC provides the secretariat for the Members of the European Parliament (MEP) Heart Group and is a founding member of two pan-European Alliances, the Alliance for Biomedical Research in Europe (BioMed Alliance), and the European Chronic Diseases Alliance (ECDA) Of course, public health—defined as ‘all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole’ (WHO, http:// www.who.int/trade/glossary/story076/en/)—is traditionally a national matter. However, experience shows that much can be achieved in Brussels to complement national policies and promote cooperation between Member States with a view to attain a higher level of health protection through all European policies and activities. This applies very well to cardiovascular diseases (CVD), the number one killer in Europe, causing 1.9 million deaths each year in the European Union at a cost of almost E196 billion a year to the EU economy. ‘In order to achieve our mission and reduce the burden of cardiovascular disease in Europe, we need to bring science to policymakers. We need to educate them so that they can make informed - decisions when legislating. We also need to mobilize them as they are strong allies when it comes to safeguarding the wellbeing of European citizens’, says Van de Werf. Indeed, for over a decade, the EU has been addressing risk factors common to all non-communicable diseases (NCDs). This approach is apparently insufficient for the promotion and protection of cardiovascular health. The ESC action in favour of an EU strategy on CVD, which should include crucial areas of action such as collection of comparable data, screening, research, and quality of care, is thus crucial. ‘Preaching to the converted is pointless. We need to get out of our scientific comfort zone. Speaking to policymakers is one way to make things happen’, added Van de Werf. To give some examples, in recent years the ESC European Affairs Committee has prepared position papers and has met with the relevant policy-makers regarding the EU Tobacco Products Directive, the Medical Devices Regulation, and the Clinical Trials Directive.
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For the past 10 years, the European Society of Cardiology (ESC) has been engaged in a constant dialogue with European Union Institutions, National Governments, International Organisations, and other relevant stakeholders to secure a policy environment favourable to cardiovascular health in Europe. European Union Public Affairs, European Union Government Affairs, or simply European Affairs are a comprehensive set of activities encompassing those actions undertaken by an interest group in order to influence European Union (EU) legislators or other public officials in favour of a specific cause. Successful European Affairs rely on relationships with governments, but also on media communications, information dissemination, and strategic communications advice. They require the involvement of expert staff with a sound knowledge of EU policy-making and the capacity to set up effective patterns of influence. At present, Brussels represents, together with Washington DC, the highest number of specialists in the world. This is due to the increasing determination of interest groups to be represented on the decision-making scene, but also—and greatly so—to the need of EU policy-makers to acquire experts’ advice on policy matters. The involvement of stakeholders contributes equally to filling the so-called democratic deficit by involving European citizens in drafting European policies alongside EU officials. With this in mind, 10 years ago the ESC chose to set up a European Affairs Committee to be assisted by a specialized European Affairs Department, with the scope of ‘channelling’ the access to policymaking, coordinating the actions of the ESC constituency, monitoring and exchanging information, and developing positions on EU legislation affecting cardiovascular health. In 2011, the ESC then joined the Brussels-based European Affairs community by opening an office in the city’s European quarter. Overall, the ESC European Affairs objectives may be summarized as follows:
3148 A ‘Cardiovascular Health Week’ was organized in the European Parliament with the support of Members of the European Parliament Heart Group for which the ESC provides the Secretariat together with the European Heart Network. In parallel, the ESC was successful in receiving EU funding for two projects: EuroHeart II focusing on CVD prevention and CardioScape, a survey of the cardiovascular disease research landscape in Europe. Unfortunately, European Affairs are often perceived as a complex and obscure activity by physicians, whose Cartesian mindset clashes with composite and often slow political processes. To draw the attention of the cardiology profession towards the importance
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of valuing policymaking for cardiovascular health, for the first time ever, a stand was dedicated to European Affairs at the ESC Congress 2014 in Barcelona. ‘It said “We are your voice in the EU” – hopefully that voice is still echoing in delegates’ minds’, concluded Van de Werf. For more information on the ESC European Affairs activities, see http://www.escardio.org/advocacy Frans Van der Werf, MD FESC [email protected], [email protected]
European Heart Journal Supplement—the Heart of the Matter Dr Roberto Ferrari discusses his return as Editor-in-chief of the newly named European Heart Journal Supplement—the Heart of the Matter
Editorial politics It was 2004 when I stepped down as Editor of the European Heart Journal Supplement (EHJs). I enjoyed my mandate as Editor working with Kim Fox, who was then Editor of the main journal at the time and there was good teamwork between us. I was surprised but very happy when the European Society of Cardiology (ESC) Board decided to invite me again to be Editor of the EHJs. In a way it can be a rather easy job: supplements are published when there is a demand for them. The Editor has to ensure that all of the manuscripts are scientifically sound and can, of course, count on the referee’s assistance for this. On the other hand, the position of Editor can be a challenging job as each issue is monothematic and the Editor often has limited space with the Sponsor to make the potential improvements. Being Editor is definitely not an easy task in the current financial climate. The general crisis within Europe has drastically reduced investments in cardiology, including those for the EHJs. There are few groups (if any) that are interested in monothematic issues, there are less innovations in cardiology and an increasing number of good journals as competitors. Cardiology has changed since 2004 and is in constant evolution. Therefore, the EHJs must also change. This challenge, I am sure, is the driving force that convinced me to re-accept the role of Editor. Together with a group of excellent Associate Editors (Francisco Ferna´ndez-Aviles, Jeroen Bax, Michael Bo¨hm, Frank Ruschitzka and
The ESC enjoys a family of nine very successful journals covering many aspects of cardiology and its sub-specialities, with a new title being launched in 2015 covering cardiovascular pharmacotherapy. Where should the EHJs – the Heart of the Matter be within this group? It would be counterproductive to compete with the established ESC journals. On the contrary, EHJs – the Heart of the Matter should offer a service to the ESC, providing scientific room for all of those aspects of the Society which are difficult to accommodate in the more specialized journals. What does this mean in practice? On behalf of the Global Scientific Activities (GSA) Committee, the EHJs – the Heart of the Matter will offer to all of the ESC Affiliate Societies the ability to publish results of their annual congresses (including abstracts), their guidelines along with comments from experts, the content of the ‘MyESC in . . .’ meetings, etc. We believe that this is a win/win situation. The Affiliate Societies will have the opportunity to disseminate their important success (in English) to all of the 28 000 worldwide subscribers of the journal and in so doing, be a part of the international cardiology community and of the ESC family. They will also enjoy the renowned prestige and the high impact factor of the EHJs – the Heart of the Matter. The ESC, on the other hand, will be officially informed of the scientific activities and successes occurring outside Europe, which will create a closer link with the Affiliate Societies. Of course, this opportunity is also available to all of the ESC Constituent Bodies: National Societies, Associations (although they
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Thomas Lu¨scher) we have decided to implement an entirely new product which will be called the European Heart Journal Supplement (EHJs) – the Heart of the Matter. The changes embrace several aspects: Editorial politics, publishing, impact factor, and pricing.
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Publishing EHJs – the Heart of the Matter is published by Oxford University Press. It has the same format as the other ESC journals, but with a new cover design and a modern layout with colour figures, interviews, short comments, case reports, etc. Every paper is reviewed by a dedicated team of reviewers and by the Editorial Board, assuring a short turnaround of 7 days. Therefore, the estimated time for an editorial decision is 2 weeks from submission. Online publication takes 2 months
from receiving the entire issue from the Editor, including language editing and proof reading.
Pricing As mentioned before, almost the entire world is facing a financial crisis and so is cardiology. As a result, together with Oxford University Press, the ESC has decided to substantially reduce costs to the sponsor by publishing the issues electronically. Thanks to this new business model, we are proud to achieve worldwide distribution of EHJs – the Heart of the Matter at a highly competitive rate namely, free of charge! Of course, the option to purchase premium printed copies remains available and the prices are also very attractive.
Impact factor No matter how innovative or fresh a scientific journal is, its impact factor provides a numeric measure of its scientific value and success. We are proud to report that the EHJs – the Heart of the Matter currently has an impact factor of 5.6 which is one of the highest for a similar journal. In summary, the previous Editor, Francisco Fernandez-Aviles, must be commended for his contribution during his term, now a new ESC adventure is starting. Please take part in many ways: by reading the EHJs – the Heart of the Matter, by helping us as a referee, by writing to us with further innovative ideas and, more importantly, by considering EHJs – the Heart of the Matter your journal and writing for it when there is a need to do so. Further information is available through the ESC Journals webpage http://www.escardio.org/journals. Roberto Ferrari, MD on behalf of the Associate Editors Department of Cardiology and LTTA Centre University Hospital of Ferrara, Italy [email protected]
Taskforce QRS A medical student project to increase survival from sudden cardiac arrest in the Southern Netherlands has grown into a successful organization
Taskforce QRS Timeline 2006 –15 An initiative was started in 2006 at the Maastricht University Medical Center, Netherlands, by Petra Schuffelen RN and Anton Gorgels MD a cardiologist, to increase resuscitation skills and knowledge in the general population. Together with 10 medical students, the
Taskforce QRS, Qualitative Resuscitation by Students, was founded. What started small has grown exponentially in recent years and has become an organization of almost 180 medical students as CPR instructors.
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already have their own journals), Working Groups, and Councils. The journal also aims to serve cardiology institutions worldwide. This is a completely new feature. Institutions usually choose the option of printing an annual brochure of their activities, results, achievements, uncertainties, etc. Why not do it through EHJs – the Heart of the Matter instead? Among the advantages is the fact that the issue will be reviewed by experts and be made available to a vast, global cardiology community with a definite impact factor. Two large cardiology institutions have already committed to an issue each for 2014, the Federal Almazov Medical Research Centre in St Petersburg, Russian Federation, and the King Abdulah Aziz Cardiac Centre in Riyadh, Saudi Arabia. These are the most innovative aspects, but EHJs – the Heart of the Matter would also like to continue its relationship with Industry, as we are convinced that the progress made in cardiology so far is the result of a cooperation between academia and industry. EHJs – the Heart of the Matter is the ideal forum for such ethical cooperation and we are offering some innovative ideas to the Sponsor. Of course, the usual symposium proceedings are welcome as well as special issues related to comments from experts on important clinical trials (a kind of ‘meet the trialist on paper’) or, of a particular Guideline, or a specific topic of interest to both industry and academia. EHJs – the Heart of the Matter can become a way for the ESC to communicate with its members on the progress of several activities such as educational programmes, EurObservational surveys, Cardiovascular Round Table progress and, especially, scientific advances at the Brussels head office.
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Mission The Taskforce QRS mission statement includes three key items. First, to provide CPR training to secondary school students and to create public support for structural CPR training in secondary schools. Second to raise more public attention for sudden cardiac arrest (SCA) and the importance of CPR in general. Third to research education of CPR in secondary school students and also to research medical students who give CPR training. Medical students trained under supervision of the Dutch Resuscitation Council as CPR instructors were accredited to accomplish this mission.
CPR training programmes
centre, ambulance tour, and insights into the development of ICD’s and pacemakers. To receive a certificate of attendance and a CPR certificate, a theoretical and practical examination must be passed. The elective course was held for the fifth time in 2014. To date 300 medical students have successfully attended the elective course. During the fifth session 100 students participated, which are 30% of the first-year medical students at Maastricht University. Taskforce QRS received the Maastricht University Student Award in 2012 for its activities at Maastricht University and secondary schools.
Research Taskforce QRS’ initiative enters an unknown area of teaching with novel roles for both teachers and pupils. This situation evokes crucial questions such as: are second-year medical students able to adequately train secondary school pupils? Are secondary school students sufficiently mature to acquire resuscitation skills, both physically and, more importantly, psychologically, such as developing the willingness, confidence, and courage to be able to handle a dramatic situation of SCA? How well are resuscitation skills retained at that age? Is mass training as effective as the classic guideline-based training? How frequent are school students effectively involved in a real resuscitation scenario after their training? How do school students cope with a resuscitation experience? Skills are assessed using computer and stored video information. Psychological aspects are assessed using specifically developed questionnaires. In this way, information of skills was gathered from 2000 students and from questionnaires in 7000 students. Preliminary results were presented at several meetings (Figure 1).1 – 3
CPR relay To increase social and media awareness for this worldwide health problem, a CPR-relay is organized in a different secondary school every year, where school students, medical students, and RNS volunteers practice 10-hours of non-stop CPR together. To raise governmental support decision-makers are trained, such as mayors, aldermen, and members of the Provincial Council and Central Government, and are also encouraged to join the CPR relay.
Activities at Maastricht University CPR training is given to (bio)medical- and health science students and a total of 1000 medical students, 1500 students of health sciences, and 300 future midwives have been trained. An annual elective course, ‘Resuscitation Medicine’, is arranged in addition to the normal curriculum for first-year medical students. This allows an in-depth view of resuscitation medicine for future physicians. The key points of the course are: aetiology and pathophysiology of cardiac arrest, physiology of cardiopulmonary resuscitation, and acute and long-term treatment. All these subjects are addressed in lectures, tutorials, and practical teaching. Lectures are given by professionals in their area of expertise. Tutorials are based on Problem-based Learning, 10 students cover five cases guided by a tutor. Practice teaching consist of CPR training, electrocardiography, visit to a dispatch
Figure 1 CPR-relay 2013. Secondary school students, medical students and professionals/volunteers working together during a 1 h CPR session.
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From 2008 to 13 the Heart Beat Survival Program (HBSP) was executed. In this programme, CPR training comprised four and a half hours of training in three sessions of 90 min, which was repeated after 1 year. The groups consisted of 15 –18 third and fourth class secondary school students. One full-instructor and one instructorcandidate were present per six students and the training materials were two manikins connected to a computer and two AED trainers per six students. The instructors used the European Resuscitation Council (ERC) four-step approach. Practical and theoretical training was combined and could be supplemented with a specifically developed CPR e-learning program (Open University, Heerlen, the Netherlands). The students’ skills were assessed after training in a test scenario. A total of 2500 secondary school students were trained in this programme. Since 2013 a new programme, the Maastricht Quantity-oriented Resuscitation Session (M-QRS), was developed to increase the number of CPR-trained secondary school students. All school classes of all ages are included in the programme. The training groups were increased to 30 –32 students. Using this concept an entire school of 2000 students could be trained in 1 month. Students are trained annually during their secondary school period, preferably in their Physical Education (PE) class. During training every student uses his own manikin. Before and after the CPR-training a questionnaire about their CPR confidence, knowledge and ability is completed. From April 2013 to June 2014 a total of 7000 secondary school students were trained.
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Future Taskforce QRS aims to train all secondary school students in the province of Limburg (50 000) in collaboration with school teachers by 2020. Limburg is just one province of the Netherlands, therefore Taskforce QRS aspires to implement the programme nationwide in cooperation with the Dutch Resuscitation Council and the Dutch Heart Foundation. More information is available at www.taskforceqrs.nl info@ taskforceqrs.nl
Taskforce QRS Board members at Maastricht University Medical Center (all medical students) from left to right: Hesam Amin (vice-chairman, [email protected]), Jules Olsthoorn (treasurer, j.olsthoorn@task forceqrs.nl), Jerremy Weerts (public relations. [email protected]), Julie Sijmons (logistics, [email protected]), Vital Houben (secretary, [email protected]), Ali Ghossein (chairman, RN, [email protected]).
References References are available as supplementary material at European Heart Journal online.
Implant-based telemonitoring in heart failure patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization defibrillators (CRT-Ds) reduces mortality, according to the IN-TIME trial. The trial randomized 664 chronic heart failure patients from 36 centres in Australia, Europe, and Israel in a 1:1 fashion to telemonitoring plus standard care or standard care alone for 12 months. The primary outcome was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment. At 1 year, the researchers found a worsened composite score in 63 (18.9%) of patients in the telemonitoring group compared with 90 (27.2%) of patients in the control group (P ¼ 0.013). The difference was primarily driven by the lower mortality in the telemonitoring group (10 deaths) compared with the control group (27 deaths). The Kaplan–Meier estimate of 1 year all-cause
mortality was 3.4% in the telemonitoring group vs. 8.7% in the control group. The researchers speculated that three mechanisms contributed to the improved clinical outcome in the telemonitoring group. One was early detection of the onset or progression of ventricular and atrial tachyarrhythmias. In IN-TIME, atrial tachyarrhythmia was the medical telemonitoring observation that most often led to patient contact and patients with a history of atrial fibrillation were more likely to benefit from telemonitoring. Other possible mechanisms were the early recognition of suboptimal device function and prompting patient interviews which revealed symptomatic worsening or medication noncompliance. The article is available at: http://www.thelancet.com/journals/ lancet/article/PIIS0140-6736(14)61176-4/abstract Jennifer Taylor
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
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IN-TIME Trial finds mortality benefit with telemonitoring in heart failure
2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism New features of the 2014 Guidelines are discussed by Professor Stavros Konstantinides, Task Force chairman The most clinically relevant new aspects of the 2014 version of the ESC Guidelines (published in Issue 43 of this volume) when compared with the previous version published in 2008 relate to:
More specifically, (1) In vitro fertilization increases the risk of pregnancy-associated VTE up to 7-fold. Blood transfusion and erythropoiesisstimulating agents are also associated with an increased risk of VTE. In children, PE is usually associated with deep vein thrombosis (DVT) and is rarely unprovoked. Serious chronic medical conditions and central venous lines are considered to be likely triggers of PE. (2) The combination of findings evaluated by the use of prediction rules allows patients with suspected PE to be classified into distinct categories of clinical or pre-test probability. Recently, both the Wells and the revised Geneva rules were simplified in an attempt to increase their adoption into clinical practice. Whichever version is used, the proportion of patients with confirmed PE can be expected to be 10% in the low-probability category, 30% in the moderate-probability category, and 65% in the high-clinical probability category. When the two-level classification is used, the proportion of patients with confirmed PE in the PE-unlikely category is 12%.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
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(1) Recently identified predisposing factors for venous thromboembolism (VTE) (2) Simplification of clinical prediction rules (3) Age-adjusted D-dimer cut-offs (4) Sub-segmental pulmonary embolism (5) Incidental, clinically unsuspected pulmonary embolism (6) Advanced risk stratification of intermediate-risk pulmonary embolism (PE) (7) Treatment and secondary prophylaxis of VTE with the new direct oral anticoagulants (NOACs) (8) Efficacy and safety of reperfusion treatment for patients at intermediate risk (9) Early discharge and home (outpatient) treatment of PE (10) Current diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) (11) Formal recommendations for the management of PE in pregnancy and of pulmonary embolism in patients with cancer.
(3) The specificity of D-dimer in suspected PE decreases steadily with age. In a multicentre, prospective management study, using an age-adjusted (age × 10 mg/L, if .50 years) instead of the ‘standard’ 500 mg/L cut-off increased the number of patients in whom PE could be excluded from 6.4 to 29.7%, without any additional false-negative findings. (4) Computed tomographic (CT) angiography showing a segmental or more proximal thrombus confirms PE. On the other hand, the clinical significance of isolated sub-segmental PE on CT angiography is questionable and further testing may be considered. In a patient with isolated sub-segmental PE and no proximal DVT, the decision on whether to treat should be made on an individual basis, taking into account the clinical probability and the bleeding risk. (5) Some experts believe that patients with incidental (unsuspected) PE on CT should be treated, especially if they have cancer and a proximal clot, but solid evidence is lacking. (6) Initial risk stratification of suspected or confirmed PE—based on the presence of shock or persistent hypotension—is recommended to identify patients at high risk of early mortality. In patients not at high risk, use of a validated clinical risk prediction score, preferably the pulmonary embolism severity index (PESI) or its simplified version (sPESI), should be considered to distinguish between low- and intermediate-risk PE. Normotensive patients in PESI Class ≥III or sPESI of ≥1 are considered to constitute an intermediate-risk group. Within this category, further risk assessment should be considered. Patients who display evidence of both RV dysfunction (by echocardiography or CT angiography) and elevated cardiac biomarker levels in the circulation (particularly a positive cardiac troponin test) should be classified into an intermediate-high-risk category. On the other hand, patients in whom the RV is normal on echocardiography or CT angiography, and/or have normal cardiac biomarker levels, belong to an intermediate- to low-risk group. (7) The results of the trials using NOACs in the treatment of VTE indicate that these agents are non-inferior (in terms of efficacy) and possibly safer (particularly in terms of major bleeding) than the standard heparin/vitamin K antagonist (VKA) regimen. The results of the trials using NOACs in the extended treatment of VTE are in line with those of the studies that tested these agents in the acute-phase treatment and standard duration of anticoagulation after PE or VTE. Therefore, NOACs are recommended as
3146 an alternative to the combination of parenteral anticoagulation with a VKA (for rivaroxaban or apixaban), or as an alternative to VKA treatment following acute-phase parenteral anticoagulation (for dabigatran or edoxaban). Rivaroxaban, dabigatran, and apixaban are approved for treatment of VTE in the European Union; edoxaban is currently under regulatory review. NOACs are not recommended in patients with severe renal impairment. (8) Routine use of primary systemic thrombolysis is not recommended in patients without shock or hypotension, but close monitoring is recommended in patients with intermediate- to high-risk PE to permit early detection of haemodynamic decompensation. Thrombolytic therapy should be considered for patients with intermediate- to high-risk PE and clinical signs of haemodynamic decompensation. Surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as alternative, ‘rescue’ procedures for patients with intermediate- to high-risk PE, in whom haemodynamic decompensation appears imminent and the anticipated bleeding risk under systemic thrombolysis is high. (9) Patients with acute, low-risk PE should be considered for early discharge and continuation of treatment at home if proper outpatient care and anticoagulant treatment can be provided.
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(10) It is recommended that, in all patients with CTEPH, the assessment of operability and decisions regarding other treatment strategies be made by a multidisciplinary team of experts. Riociguat is recommended in symptomatic patients who have been classified as having inoperable CTEPH by a CTEPH team including at least one experienced pulmonary endarterectomy (PEA) surgeon, or have persistent/recurrent CTEPH after surgical treatment. (11) Suspicion of PE in pregnancy warrants formal diagnostic assessment with validated methods. Venous compression ultrasonography may be considered in order to avoid unnecessary irradiation in pregnant patients, as a diagnosis of proximal DVT confirms PE. A weight-adjusted dose of LMWH is the recommended therapy during pregnancy in patients without shock or hypotension. For patients with PE and cancer, weightadjusted subcutaneous LMWH should be considered for the first 3–6 months; extended anticoagulation (beyond the first 3–6 months) should be considered for an indefinite period or until the cancer is cured. Stavros V. Konstantinides, MD, PhD, FESC ESC Task Force Chairman [email protected]
(1) Assessment of haemodynamic stability of the patient and clinical probability of pulmonary embolism (PE) is the basis of all diagnostic strategies. (2) Appropriate use of D-dimer testing may reduce the need for unnecessary imaging and irradiation. (3) While computed tomographic angiography plays a key role in diagnostic algorithms, ventilation-perfusion (V/Q), compression venous ultrasonography, and emergency echocardiography may be helpful in management decisions. (4) Clinical assessment may identify patients at high risk (with shock or hypotension) requiring primary revascularization therapy, and patients at low risk of early death despite confirmed PE (Pulmonary Embolism Severity Index classes I or II) who can be considered for early discharge if appropriately anti-coagulated. (5) Among the remaining patients, those with signs of both right-ventricular overload and positive humoral biomarkers (troponin, BNP) represent an intermediate- to high-risk group which should be monitored, as they may require rescue reperfusion therapy if clinical signs of haemodynamic decompensation appear. (6) Primary reperfusion treatment, particularly systemic thrombolysis, is the treatment of choice for patients with high-risk PE. (7) Surgical pulmonary embolectomy and percutaneous catheter-directed treatment are alternative methods of primary and rescue reperfusion treatment. (8) For most cases of acute PE without haemodynamic compromise, low-molecular-weight heparin or fondaparinux is the initial treatment of choice. Unfractionated heparin should be used in haemodynamically unstable patients and those with severe renal dysfunction. (9) The non-vitamin-K-dependent oral anticoagulants (NOACs; direct inhibitors of factor Xa or thrombin) are non-inferior in terms of efficacy and possibly safer, particularly in terms of major bleeding, than the standard anticoagulation regimen consisting of heparin followed by a vitamin K antagonist. (10) Management of PE in patients with cancer and in pregnancy, duration of anti-coagulation after initial episode, and management of patients with persisting symptoms and suspected/confirmed chronic thromboembolic pulmonary hypertension after PE all require specific considerations and may need to follow separate recommendations—see guidelines. These Guidelines were published in Issue 43 of this volume. For more information, see http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/essential-message-slideset.aspx Stavros Konstantinides: MD and Adam Torbiki, MD
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The ‘Ten Commandments’ for ESC guidelines on pulmonary embolism
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European Society of Cardiology European Affairs: bringing science to policy-makers Frans Van de Werf, Chairman of the European Society of Cardiology European Affairs Committee since 2010, explains what European Affairs is all about and why it is key for a medical society to engage in European Union policy-making
(1) Promote the interests of the ESC and its constituent bodies at the level of EU institutions (2) Secure a European environment favourable for tackling cardiovascular disease (3) Ensure that cardiovascular health is considered a key priority by decision makers across Europe To achieve these objectives, ESC European Affairs follow policy activities and devise initiatives in the following areas: Prevention: Activities aim at stimulating the development of national strategies to combat heart disease by providing practical tools to act both at population and individual levels.
Research: The European Affairs Committee strives to improve the standards of cardiovascular research in Europe through the identification and promotion of research needs and priorities. Regulatory affairs: The goal is to establish an open dialogue and exchange with European authorities on regulatory aspects. Activities focus mainly on drugs and medical devices. Registries: The European Affairs Committee is dedicated to ensuring political support for the development of comparable cardiovascular data in the European Union. Groups: The ESC provides the secretariat for the Members of the European Parliament (MEP) Heart Group and is a founding member of two pan-European Alliances, the Alliance for Biomedical Research in Europe (BioMed Alliance), and the European Chronic Diseases Alliance (ECDA) Of course, public health—defined as ‘all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole’ (WHO, http:// www.who.int/trade/glossary/story076/en/)—is traditionally a national matter. However, experience shows that much can be achieved in Brussels to complement national policies and promote cooperation between Member States with a view to attain a higher level of health protection through all European policies and activities. This applies very well to cardiovascular diseases (CVD), the number one killer in Europe, causing 1.9 million deaths each year in the European Union at a cost of almost E196 billion a year to the EU economy. ‘In order to achieve our mission and reduce the burden of cardiovascular disease in Europe, we need to bring science to policymakers. We need to educate them so that they can make informed - decisions when legislating. We also need to mobilize them as they are strong allies when it comes to safeguarding the wellbeing of European citizens’, says Van de Werf. Indeed, for over a decade, the EU has been addressing risk factors common to all non-communicable diseases (NCDs). This approach is apparently insufficient for the promotion and protection of cardiovascular health. The ESC action in favour of an EU strategy on CVD, which should include crucial areas of action such as collection of comparable data, screening, research, and quality of care, is thus crucial. ‘Preaching to the converted is pointless. We need to get out of our scientific comfort zone. Speaking to policymakers is one way to make things happen’, added Van de Werf. To give some examples, in recent years the ESC European Affairs Committee has prepared position papers and has met with the relevant policy-makers regarding the EU Tobacco Products Directive, the Medical Devices Regulation, and the Clinical Trials Directive.
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For the past 10 years, the European Society of Cardiology (ESC) has been engaged in a constant dialogue with European Union Institutions, National Governments, International Organisations, and other relevant stakeholders to secure a policy environment favourable to cardiovascular health in Europe. European Union Public Affairs, European Union Government Affairs, or simply European Affairs are a comprehensive set of activities encompassing those actions undertaken by an interest group in order to influence European Union (EU) legislators or other public officials in favour of a specific cause. Successful European Affairs rely on relationships with governments, but also on media communications, information dissemination, and strategic communications advice. They require the involvement of expert staff with a sound knowledge of EU policy-making and the capacity to set up effective patterns of influence. At present, Brussels represents, together with Washington DC, the highest number of specialists in the world. This is due to the increasing determination of interest groups to be represented on the decision-making scene, but also—and greatly so—to the need of EU policy-makers to acquire experts’ advice on policy matters. The involvement of stakeholders contributes equally to filling the so-called democratic deficit by involving European citizens in drafting European policies alongside EU officials. With this in mind, 10 years ago the ESC chose to set up a European Affairs Committee to be assisted by a specialized European Affairs Department, with the scope of ‘channelling’ the access to policymaking, coordinating the actions of the ESC constituency, monitoring and exchanging information, and developing positions on EU legislation affecting cardiovascular health. In 2011, the ESC then joined the Brussels-based European Affairs community by opening an office in the city’s European quarter. Overall, the ESC European Affairs objectives may be summarized as follows:
3148 A ‘Cardiovascular Health Week’ was organized in the European Parliament with the support of Members of the European Parliament Heart Group for which the ESC provides the Secretariat together with the European Heart Network. In parallel, the ESC was successful in receiving EU funding for two projects: EuroHeart II focusing on CVD prevention and CardioScape, a survey of the cardiovascular disease research landscape in Europe. Unfortunately, European Affairs are often perceived as a complex and obscure activity by physicians, whose Cartesian mindset clashes with composite and often slow political processes. To draw the attention of the cardiology profession towards the importance
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of valuing policymaking for cardiovascular health, for the first time ever, a stand was dedicated to European Affairs at the ESC Congress 2014 in Barcelona. ‘It said “We are your voice in the EU” – hopefully that voice is still echoing in delegates’ minds’, concluded Van de Werf. For more information on the ESC European Affairs activities, see http://www.escardio.org/advocacy Frans Van der Werf, MD FESC [email protected], [email protected]
European Heart Journal Supplement—the Heart of the Matter Dr Roberto Ferrari discusses his return as Editor-in-chief of the newly named European Heart Journal Supplement—the Heart of the Matter
Editorial politics It was 2004 when I stepped down as Editor of the European Heart Journal Supplement (EHJs). I enjoyed my mandate as Editor working with Kim Fox, who was then Editor of the main journal at the time and there was good teamwork between us. I was surprised but very happy when the European Society of Cardiology (ESC) Board decided to invite me again to be Editor of the EHJs. In a way it can be a rather easy job: supplements are published when there is a demand for them. The Editor has to ensure that all of the manuscripts are scientifically sound and can, of course, count on the referee’s assistance for this. On the other hand, the position of Editor can be a challenging job as each issue is monothematic and the Editor often has limited space with the Sponsor to make the potential improvements. Being Editor is definitely not an easy task in the current financial climate. The general crisis within Europe has drastically reduced investments in cardiology, including those for the EHJs. There are few groups (if any) that are interested in monothematic issues, there are less innovations in cardiology and an increasing number of good journals as competitors. Cardiology has changed since 2004 and is in constant evolution. Therefore, the EHJs must also change. This challenge, I am sure, is the driving force that convinced me to re-accept the role of Editor. Together with a group of excellent Associate Editors (Francisco Ferna´ndez-Aviles, Jeroen Bax, Michael Bo¨hm, Frank Ruschitzka and
The ESC enjoys a family of nine very successful journals covering many aspects of cardiology and its sub-specialities, with a new title being launched in 2015 covering cardiovascular pharmacotherapy. Where should the EHJs – the Heart of the Matter be within this group? It would be counterproductive to compete with the established ESC journals. On the contrary, EHJs – the Heart of the Matter should offer a service to the ESC, providing scientific room for all of those aspects of the Society which are difficult to accommodate in the more specialized journals. What does this mean in practice? On behalf of the Global Scientific Activities (GSA) Committee, the EHJs – the Heart of the Matter will offer to all of the ESC Affiliate Societies the ability to publish results of their annual congresses (including abstracts), their guidelines along with comments from experts, the content of the ‘MyESC in . . .’ meetings, etc. We believe that this is a win/win situation. The Affiliate Societies will have the opportunity to disseminate their important success (in English) to all of the 28 000 worldwide subscribers of the journal and in so doing, be a part of the international cardiology community and of the ESC family. They will also enjoy the renowned prestige and the high impact factor of the EHJs – the Heart of the Matter. The ESC, on the other hand, will be officially informed of the scientific activities and successes occurring outside Europe, which will create a closer link with the Affiliate Societies. Of course, this opportunity is also available to all of the ESC Constituent Bodies: National Societies, Associations (although they
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Thomas Lu¨scher) we have decided to implement an entirely new product which will be called the European Heart Journal Supplement (EHJs) – the Heart of the Matter. The changes embrace several aspects: Editorial politics, publishing, impact factor, and pricing.
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Publishing EHJs – the Heart of the Matter is published by Oxford University Press. It has the same format as the other ESC journals, but with a new cover design and a modern layout with colour figures, interviews, short comments, case reports, etc. Every paper is reviewed by a dedicated team of reviewers and by the Editorial Board, assuring a short turnaround of 7 days. Therefore, the estimated time for an editorial decision is 2 weeks from submission. Online publication takes 2 months
from receiving the entire issue from the Editor, including language editing and proof reading.
Pricing As mentioned before, almost the entire world is facing a financial crisis and so is cardiology. As a result, together with Oxford University Press, the ESC has decided to substantially reduce costs to the sponsor by publishing the issues electronically. Thanks to this new business model, we are proud to achieve worldwide distribution of EHJs – the Heart of the Matter at a highly competitive rate namely, free of charge! Of course, the option to purchase premium printed copies remains available and the prices are also very attractive.
Impact factor No matter how innovative or fresh a scientific journal is, its impact factor provides a numeric measure of its scientific value and success. We are proud to report that the EHJs – the Heart of the Matter currently has an impact factor of 5.6 which is one of the highest for a similar journal. In summary, the previous Editor, Francisco Fernandez-Aviles, must be commended for his contribution during his term, now a new ESC adventure is starting. Please take part in many ways: by reading the EHJs – the Heart of the Matter, by helping us as a referee, by writing to us with further innovative ideas and, more importantly, by considering EHJs – the Heart of the Matter your journal and writing for it when there is a need to do so. Further information is available through the ESC Journals webpage http://www.escardio.org/journals. Roberto Ferrari, MD on behalf of the Associate Editors Department of Cardiology and LTTA Centre University Hospital of Ferrara, Italy [email protected]
Taskforce QRS A medical student project to increase survival from sudden cardiac arrest in the Southern Netherlands has grown into a successful organization
Taskforce QRS Timeline 2006 –15 An initiative was started in 2006 at the Maastricht University Medical Center, Netherlands, by Petra Schuffelen RN and Anton Gorgels MD a cardiologist, to increase resuscitation skills and knowledge in the general population. Together with 10 medical students, the
Taskforce QRS, Qualitative Resuscitation by Students, was founded. What started small has grown exponentially in recent years and has become an organization of almost 180 medical students as CPR instructors.
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already have their own journals), Working Groups, and Councils. The journal also aims to serve cardiology institutions worldwide. This is a completely new feature. Institutions usually choose the option of printing an annual brochure of their activities, results, achievements, uncertainties, etc. Why not do it through EHJs – the Heart of the Matter instead? Among the advantages is the fact that the issue will be reviewed by experts and be made available to a vast, global cardiology community with a definite impact factor. Two large cardiology institutions have already committed to an issue each for 2014, the Federal Almazov Medical Research Centre in St Petersburg, Russian Federation, and the King Abdulah Aziz Cardiac Centre in Riyadh, Saudi Arabia. These are the most innovative aspects, but EHJs – the Heart of the Matter would also like to continue its relationship with Industry, as we are convinced that the progress made in cardiology so far is the result of a cooperation between academia and industry. EHJs – the Heart of the Matter is the ideal forum for such ethical cooperation and we are offering some innovative ideas to the Sponsor. Of course, the usual symposium proceedings are welcome as well as special issues related to comments from experts on important clinical trials (a kind of ‘meet the trialist on paper’) or, of a particular Guideline, or a specific topic of interest to both industry and academia. EHJs – the Heart of the Matter can become a way for the ESC to communicate with its members on the progress of several activities such as educational programmes, EurObservational surveys, Cardiovascular Round Table progress and, especially, scientific advances at the Brussels head office.
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Mission The Taskforce QRS mission statement includes three key items. First, to provide CPR training to secondary school students and to create public support for structural CPR training in secondary schools. Second to raise more public attention for sudden cardiac arrest (SCA) and the importance of CPR in general. Third to research education of CPR in secondary school students and also to research medical students who give CPR training. Medical students trained under supervision of the Dutch Resuscitation Council as CPR instructors were accredited to accomplish this mission.
CPR training programmes
centre, ambulance tour, and insights into the development of ICD’s and pacemakers. To receive a certificate of attendance and a CPR certificate, a theoretical and practical examination must be passed. The elective course was held for the fifth time in 2014. To date 300 medical students have successfully attended the elective course. During the fifth session 100 students participated, which are 30% of the first-year medical students at Maastricht University. Taskforce QRS received the Maastricht University Student Award in 2012 for its activities at Maastricht University and secondary schools.
Research Taskforce QRS’ initiative enters an unknown area of teaching with novel roles for both teachers and pupils. This situation evokes crucial questions such as: are second-year medical students able to adequately train secondary school pupils? Are secondary school students sufficiently mature to acquire resuscitation skills, both physically and, more importantly, psychologically, such as developing the willingness, confidence, and courage to be able to handle a dramatic situation of SCA? How well are resuscitation skills retained at that age? Is mass training as effective as the classic guideline-based training? How frequent are school students effectively involved in a real resuscitation scenario after their training? How do school students cope with a resuscitation experience? Skills are assessed using computer and stored video information. Psychological aspects are assessed using specifically developed questionnaires. In this way, information of skills was gathered from 2000 students and from questionnaires in 7000 students. Preliminary results were presented at several meetings (Figure 1).1 – 3
CPR relay To increase social and media awareness for this worldwide health problem, a CPR-relay is organized in a different secondary school every year, where school students, medical students, and RNS volunteers practice 10-hours of non-stop CPR together. To raise governmental support decision-makers are trained, such as mayors, aldermen, and members of the Provincial Council and Central Government, and are also encouraged to join the CPR relay.
Activities at Maastricht University CPR training is given to (bio)medical- and health science students and a total of 1000 medical students, 1500 students of health sciences, and 300 future midwives have been trained. An annual elective course, ‘Resuscitation Medicine’, is arranged in addition to the normal curriculum for first-year medical students. This allows an in-depth view of resuscitation medicine for future physicians. The key points of the course are: aetiology and pathophysiology of cardiac arrest, physiology of cardiopulmonary resuscitation, and acute and long-term treatment. All these subjects are addressed in lectures, tutorials, and practical teaching. Lectures are given by professionals in their area of expertise. Tutorials are based on Problem-based Learning, 10 students cover five cases guided by a tutor. Practice teaching consist of CPR training, electrocardiography, visit to a dispatch
Figure 1 CPR-relay 2013. Secondary school students, medical students and professionals/volunteers working together during a 1 h CPR session.
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From 2008 to 13 the Heart Beat Survival Program (HBSP) was executed. In this programme, CPR training comprised four and a half hours of training in three sessions of 90 min, which was repeated after 1 year. The groups consisted of 15 –18 third and fourth class secondary school students. One full-instructor and one instructorcandidate were present per six students and the training materials were two manikins connected to a computer and two AED trainers per six students. The instructors used the European Resuscitation Council (ERC) four-step approach. Practical and theoretical training was combined and could be supplemented with a specifically developed CPR e-learning program (Open University, Heerlen, the Netherlands). The students’ skills were assessed after training in a test scenario. A total of 2500 secondary school students were trained in this programme. Since 2013 a new programme, the Maastricht Quantity-oriented Resuscitation Session (M-QRS), was developed to increase the number of CPR-trained secondary school students. All school classes of all ages are included in the programme. The training groups were increased to 30 –32 students. Using this concept an entire school of 2000 students could be trained in 1 month. Students are trained annually during their secondary school period, preferably in their Physical Education (PE) class. During training every student uses his own manikin. Before and after the CPR-training a questionnaire about their CPR confidence, knowledge and ability is completed. From April 2013 to June 2014 a total of 7000 secondary school students were trained.
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Future Taskforce QRS aims to train all secondary school students in the province of Limburg (50 000) in collaboration with school teachers by 2020. Limburg is just one province of the Netherlands, therefore Taskforce QRS aspires to implement the programme nationwide in cooperation with the Dutch Resuscitation Council and the Dutch Heart Foundation. More information is available at www.taskforceqrs.nl info@ taskforceqrs.nl
Taskforce QRS Board members at Maastricht University Medical Center (all medical students) from left to right: Hesam Amin (vice-chairman, [email protected]), Jules Olsthoorn (treasurer, j.olsthoorn@task forceqrs.nl), Jerremy Weerts (public relations. [email protected]), Julie Sijmons (logistics, [email protected]), Vital Houben (secretary, [email protected]), Ali Ghossein (chairman, RN, [email protected]).
References References are available as supplementary material at European Heart Journal online.
Implant-based telemonitoring in heart failure patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization defibrillators (CRT-Ds) reduces mortality, according to the IN-TIME trial. The trial randomized 664 chronic heart failure patients from 36 centres in Australia, Europe, and Israel in a 1:1 fashion to telemonitoring plus standard care or standard care alone for 12 months. The primary outcome was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment. At 1 year, the researchers found a worsened composite score in 63 (18.9%) of patients in the telemonitoring group compared with 90 (27.2%) of patients in the control group (P ¼ 0.013). The difference was primarily driven by the lower mortality in the telemonitoring group (10 deaths) compared with the control group (27 deaths). The Kaplan–Meier estimate of 1 year all-cause
mortality was 3.4% in the telemonitoring group vs. 8.7% in the control group. The researchers speculated that three mechanisms contributed to the improved clinical outcome in the telemonitoring group. One was early detection of the onset or progression of ventricular and atrial tachyarrhythmias. In IN-TIME, atrial tachyarrhythmia was the medical telemonitoring observation that most often led to patient contact and patients with a history of atrial fibrillation were more likely to benefit from telemonitoring. Other possible mechanisms were the early recognition of suboptimal device function and prompting patient interviews which revealed symptomatic worsening or medication noncompliance. The article is available at: http://www.thelancet.com/journals/ lancet/article/PIIS0140-6736(14)61176-4/abstract Jennifer Taylor
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
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IN-TIME Trial finds mortality benefit with telemonitoring in heart failure
