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European Society of Cardiology Congress 2013 highlights
Keith AA Fox*
European Society of Cardiology Congress 2013, Amsterdam, The Netherlands, 31 August–4 September 2013 The European Society of Cardiology (ESC) Congress in 2013 met in Amsterdam (The Netherlands) as an innovative and interactive congress involving more than 30,000 participants. There were 10,490 abstract submissions and a total of 227 hotline, basic science hotline and trial update submissions. Participants were involved from more than 150 countries. To make the congress manageable for participants, related topics were grouped together in ‘villages’ and a smart electronic application allowed the participants to guide their way through the congress and choose the sessions of interest. The innovative new program was initiated by the ESC Congress Programme Committee and the Congress Chair (Keith AA Fox, Chair 2012–2014) has responsibility for the design and delivery of the scientific program. The spotlight of the congress was ‘the heart interacting with systemic organs’, chosen because of the importance of cardiovascular disease conditions crossing conventional boundaries. In all 572 abstracts, the work involved an interaction between the heart and another organ, such as the brain, lungs, kidney, vasculature or inflammation system. In addition, innovative new approaches linked basic science and clinical science and the new ‘hubs of the congress’ allowed excellent interaction and exchange of ideas. The European Society of Cardiology (ESC) Congress is the largest cardiology congress and, despite the prevailing economic climate, there was increased attendance not only from the 55 member countries of the ESC, but also affiliated countries. There were 34 linked cardiology sessions with other organizations, worldwide and record participation from cardiologists and scientists from countries as distant as Japan, Brazil, Argentina, China and Russia. The multinational nature of the congress provides unique opportunities for interactions and discussions about research and clinical practice. We have much to learn from each other.
KEYWORDS
• 2013 • congress • ESC Congress • European
Society of Cardiology • highlights
New ESC guidelines In collaboration with partner organizations, four new ESC guidelines were presented on the management of stable coronary artery disease, diabetes and prediabetes in cardiovascular disease, cardiac pacing and cardiac synchronization therapy, and arterial hypertension.
part of
*Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; [email protected]
10.2217/FCA.13.91 © 2014 Future Medicine Ltd
Future Cardiol. (2014) 10(1), 23–26
ISSN 1479-6678
23
Conference scene Fox A key element of the new hypertension guidelines concerned the single-blood pressure target of 140/90 mmHg (140/85 mmHg in diabetics). In addition, out-of-office blood pressure monitoring has an important role for management and there is a greater emphasis on assessing total cardiovascular risk. The new ESC guidelines on diabetes endorse the use of HbA1C levels in the diagnosis of diabetes and provide important simplification of cardiovascular risk assessment in patients with diabetes. Practical clinical guidance is also provided in the guidelines on pacing and in the guidelines on stable coronary artery disease, where there is greater emphasis on modern imaging techniques to assess the extent of ischemia. Hotlines The TASTE trial was a large-scale randomized trial assessing the role of thrombus aspiration [1]. This study randomized 7244 patients and the primary end point was time to all-cause mortality by day 30. Thrombus aspiration did not have a significant impact on this relatively early end point (2.8% for thrombus aspiration and 3% for the percutaneous coronary intervention [PCI]-only arm). The risk of rehospitalization was also similar at 0.5% in the PCI plus thrombus aspiration arm and 0.9% in the PCI-only arm. In conclusion, investigators state that the trial demonstrates no advantage for thrombus aspiration in conjunction with primary PCI. The study was also novel in that the randomization occurred within a registry population, providing a potential model for cost-effective strategy trials for the future. Although novel anticoagulants have been shown to be as effective or more effective than warfarin for the prevention of stroke and systemic embolism in patients with atrial fibrillation, it is unknown whether such agents may be effective anticoagulants in patients with mechanical heart valves. The RE-ALIGN study randomized patients to dabigatran etexilate after heart valve replacement [2]. The population comprised of two cohorts: patients with an aortic or mitral valve replacement in the past 7 days or patients who had received a mechanical mitral valve at least 3 months prior to randomization. The doses of dabigatran were adjusted according to renal function. For those with creatinine clearance >100 ml/min, the dose was 300 mg twice daily (double the
24
Future Cardiol. (2014) 10(1)
highest dose used in the atrial fibrillation trial). RE-ALIGN was terminated early due to excesses in thromboembolic and bleeding events in the dabigatran group (death or a first major thromboembolic event ocurred in 9% of dabigatran and 5% of warfarin patients). Bleeding was more frequent with dabigatran (27 vs 12% warfarin). Consequently, the findings suggest that this novel anticoagulant (and perhaps others) is not appropriate for patients with mechanical heart valves. A novel anti-Xa inhibitor (edoxaban) was tested against warfarin for the prevention of recurrent venous thromboembolism (VTE) in patients who had initially been treated with heparin [3] . In this Hokusai study, 8240 patients with acute symptomatic venous thrombosis or pulmonary embolism were randomized to 60 mg daily of edoxaban or warfarin with a target international normalized ratio of 2/3. The trial met its primary objective of establishing noninferiority (recurrent VTE 3.2 vs 3.5% warfarin). In those with severe pulmonary embolism and evidence of right ventricular dysfunction or elevated natriuretic peptides, edoxaban reduced current VTE compared with warfarin. Rates of clinically relevant bleeding were lower with edoxaban compared with warfarin (8.5 vs 10.3%; p = 0.004). This study differed from others in that it tested whether this novel anticoagulant could be used as an alternative to warfarin in those already treated with heparin for VTE. There is uncertainty about the optimal management of additional coronary stenoses, other than the culprit lesions, in patients presenting with acute ST segment elevation myocardial infarction (MI). In the PRAMI trial, 465 patients with acute ST elevation MI and multivessel coronary artery disease were randomized to ‘preventive PCI’ or ‘no preventive PCI’ in other lesions of >50% stenosis [4]. The trial was stopped early due to a highly significant difference in the primary outcome in favor of the preventive PCI strategy (p ≤ 0.001). The primary outcome showed a remarkably large difference: 9 versus 22.9% in the preventative PCI and no preventive PCI group, respectively (p ≤ 0.001). Although this is a relatively small study, it raises the potential to change practice and further trials are underway. Whether pretreatment with prasugrel at the time of diagnosis of non-ST segment elevation MI may reduce complications was tested in the
future science group
European Society of Cardiology Congress 2013 highlights ACCOAST trial [5]. A total of 4033 patients were randomized to 30 mg of prasugrel at the time of diagnosis and an additional 30 mg at PCI. In the control group they received placebo and 60 mg prasugrel following angiography. There was no evidence of benefit but a nearly twofold increase in thrombolysis in MI major bleeding (hazard ratio: 1.90; 95% CI: 1.19–3.02). The study does not support pretreatment with prasugrel prior to angiography. In the In-TIME trial, the impact of home monitoring on the clinical status was tested in heart failure patients within impaired left ventricular function. The study randomized 664 patients with heart failure and by 12 months, significantly fewer patients in the home monitoring group experienced worsening heart failure (18.9 vs 27.5%; p
European Society of Cardiology Congress 2013 highlights
Keith AA Fox*
European Society of Cardiology Congress 2013, Amsterdam, The Netherlands, 31 August–4 September 2013 The European Society of Cardiology (ESC) Congress in 2013 met in Amsterdam (The Netherlands) as an innovative and interactive congress involving more than 30,000 participants. There were 10,490 abstract submissions and a total of 227 hotline, basic science hotline and trial update submissions. Participants were involved from more than 150 countries. To make the congress manageable for participants, related topics were grouped together in ‘villages’ and a smart electronic application allowed the participants to guide their way through the congress and choose the sessions of interest. The innovative new program was initiated by the ESC Congress Programme Committee and the Congress Chair (Keith AA Fox, Chair 2012–2014) has responsibility for the design and delivery of the scientific program. The spotlight of the congress was ‘the heart interacting with systemic organs’, chosen because of the importance of cardiovascular disease conditions crossing conventional boundaries. In all 572 abstracts, the work involved an interaction between the heart and another organ, such as the brain, lungs, kidney, vasculature or inflammation system. In addition, innovative new approaches linked basic science and clinical science and the new ‘hubs of the congress’ allowed excellent interaction and exchange of ideas. The European Society of Cardiology (ESC) Congress is the largest cardiology congress and, despite the prevailing economic climate, there was increased attendance not only from the 55 member countries of the ESC, but also affiliated countries. There were 34 linked cardiology sessions with other organizations, worldwide and record participation from cardiologists and scientists from countries as distant as Japan, Brazil, Argentina, China and Russia. The multinational nature of the congress provides unique opportunities for interactions and discussions about research and clinical practice. We have much to learn from each other.
KEYWORDS
• 2013 • congress • ESC Congress • European
Society of Cardiology • highlights
New ESC guidelines In collaboration with partner organizations, four new ESC guidelines were presented on the management of stable coronary artery disease, diabetes and prediabetes in cardiovascular disease, cardiac pacing and cardiac synchronization therapy, and arterial hypertension.
part of
*Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; [email protected]
10.2217/FCA.13.91 © 2014 Future Medicine Ltd
Future Cardiol. (2014) 10(1), 23–26
ISSN 1479-6678
23
Conference scene Fox A key element of the new hypertension guidelines concerned the single-blood pressure target of 140/90 mmHg (140/85 mmHg in diabetics). In addition, out-of-office blood pressure monitoring has an important role for management and there is a greater emphasis on assessing total cardiovascular risk. The new ESC guidelines on diabetes endorse the use of HbA1C levels in the diagnosis of diabetes and provide important simplification of cardiovascular risk assessment in patients with diabetes. Practical clinical guidance is also provided in the guidelines on pacing and in the guidelines on stable coronary artery disease, where there is greater emphasis on modern imaging techniques to assess the extent of ischemia. Hotlines The TASTE trial was a large-scale randomized trial assessing the role of thrombus aspiration [1]. This study randomized 7244 patients and the primary end point was time to all-cause mortality by day 30. Thrombus aspiration did not have a significant impact on this relatively early end point (2.8% for thrombus aspiration and 3% for the percutaneous coronary intervention [PCI]-only arm). The risk of rehospitalization was also similar at 0.5% in the PCI plus thrombus aspiration arm and 0.9% in the PCI-only arm. In conclusion, investigators state that the trial demonstrates no advantage for thrombus aspiration in conjunction with primary PCI. The study was also novel in that the randomization occurred within a registry population, providing a potential model for cost-effective strategy trials for the future. Although novel anticoagulants have been shown to be as effective or more effective than warfarin for the prevention of stroke and systemic embolism in patients with atrial fibrillation, it is unknown whether such agents may be effective anticoagulants in patients with mechanical heart valves. The RE-ALIGN study randomized patients to dabigatran etexilate after heart valve replacement [2]. The population comprised of two cohorts: patients with an aortic or mitral valve replacement in the past 7 days or patients who had received a mechanical mitral valve at least 3 months prior to randomization. The doses of dabigatran were adjusted according to renal function. For those with creatinine clearance >100 ml/min, the dose was 300 mg twice daily (double the
24
Future Cardiol. (2014) 10(1)
highest dose used in the atrial fibrillation trial). RE-ALIGN was terminated early due to excesses in thromboembolic and bleeding events in the dabigatran group (death or a first major thromboembolic event ocurred in 9% of dabigatran and 5% of warfarin patients). Bleeding was more frequent with dabigatran (27 vs 12% warfarin). Consequently, the findings suggest that this novel anticoagulant (and perhaps others) is not appropriate for patients with mechanical heart valves. A novel anti-Xa inhibitor (edoxaban) was tested against warfarin for the prevention of recurrent venous thromboembolism (VTE) in patients who had initially been treated with heparin [3] . In this Hokusai study, 8240 patients with acute symptomatic venous thrombosis or pulmonary embolism were randomized to 60 mg daily of edoxaban or warfarin with a target international normalized ratio of 2/3. The trial met its primary objective of establishing noninferiority (recurrent VTE 3.2 vs 3.5% warfarin). In those with severe pulmonary embolism and evidence of right ventricular dysfunction or elevated natriuretic peptides, edoxaban reduced current VTE compared with warfarin. Rates of clinically relevant bleeding were lower with edoxaban compared with warfarin (8.5 vs 10.3%; p = 0.004). This study differed from others in that it tested whether this novel anticoagulant could be used as an alternative to warfarin in those already treated with heparin for VTE. There is uncertainty about the optimal management of additional coronary stenoses, other than the culprit lesions, in patients presenting with acute ST segment elevation myocardial infarction (MI). In the PRAMI trial, 465 patients with acute ST elevation MI and multivessel coronary artery disease were randomized to ‘preventive PCI’ or ‘no preventive PCI’ in other lesions of >50% stenosis [4]. The trial was stopped early due to a highly significant difference in the primary outcome in favor of the preventive PCI strategy (p ≤ 0.001). The primary outcome showed a remarkably large difference: 9 versus 22.9% in the preventative PCI and no preventive PCI group, respectively (p ≤ 0.001). Although this is a relatively small study, it raises the potential to change practice and further trials are underway. Whether pretreatment with prasugrel at the time of diagnosis of non-ST segment elevation MI may reduce complications was tested in the
future science group
European Society of Cardiology Congress 2013 highlights ACCOAST trial [5]. A total of 4033 patients were randomized to 30 mg of prasugrel at the time of diagnosis and an additional 30 mg at PCI. In the control group they received placebo and 60 mg prasugrel following angiography. There was no evidence of benefit but a nearly twofold increase in thrombolysis in MI major bleeding (hazard ratio: 1.90; 95% CI: 1.19–3.02). The study does not support pretreatment with prasugrel prior to angiography. In the In-TIME trial, the impact of home monitoring on the clinical status was tested in heart failure patients within impaired left ventricular function. The study randomized 664 patients with heart failure and by 12 months, significantly fewer patients in the home monitoring group experienced worsening heart failure (18.9 vs 27.5%; p
