31-08-2013 t/m 4-09-2013 ESC Congres 2013 Amsterdam (NH)

[oma]

In this 4.5-minute video interview conducted at the ESC conference, Professor Frans Van de Werf gives an overview of what he considers to be some of the 10 most promising new and future therapies that will affect clinical practice for cardiovascular specialists.

Interview with Professor Frans Van de Werf - ESC 2013: Top 10 most promising therapies

[oma]

Amsterdam, The Netherlands –Tuesday 3 September 2013: The use of oral anticoagulation for stroke prevention in atrial fibrillation (AF) has not improved in the last 10 years, according to the first results of the Atrial Fibrillation General Pilot Registry presented at ESC Congress 2013 today by Professor Gregory Lip (UK).

Professor Lip said: “A decade ago the ESC conducted a registry on AF management as part of the Euro Heart Survey. Since then new treatments have become available and the ESC has published new guidelines on the management of AF.1,2 The time was right for a new registry to assess adherence to guidelines and how management has changed over time.”

The Atrial Fibrillation General Pilot Registry is part of the ESC’s EORP programme3 and includes over 3,000 patients in 9 countries. Data was collected on implementation and outcomes for catheter ablation, new antithrombotic drugs and new antiarrhythmic agents. The data was compared to Euro Heart Survey data from 10 years ago, which was collected using a similar study design.

The baseline results of the pilot registry, presented for the first time today, provide an important snapshot of AF epidemiology and management in 9 ESC member countries.

Use of oral anticoagulation for stroke prevention remained suboptimal and was broadly similar to 10 years ago. Approximately 65% of patients with AF received oral anticoagulation for stroke prevention (usually vitamin K antagonists). Of those anticoagulated, novel oral anticoagulants were used in less than 10% of patients. Independent predictors of oral anticoagulant use were younger age, high CHA2DS2-VASc score, BMI, hyperthyroidism and prior stroke – whilst predictors of less use were older age, female gender, high systolic blood pressure, high HAS-BLED score and chronic kidney disease.

Professor Lip said: “The proportion of patients with AF who receive oral anticoagulation hasn’t increased in the last 10 years despite the introduction of new anticoagulants. The current focus is the initial identification of ‘truly low risk’ patients with AF who do not need any antithrombotic therapy; subsequent to this step, patients with AF and one or more stroke risk factors can be offered effective stroke prevention, which is oral anticoagulation.”

As with the Euro Heart survey of a decade ago, common comorbidities in AF patients remain hypertension, coronary disease and heart failure. Lone AF was evident in only <7% of patients, and importantly, asymptomatic AF is a common occurrence.

Professor Lip said: “Asymptomatic AF is common and it’s often not picked up until something bad happens. In many cases, asymptomatic AF is first diagnosed when patients present with a complication, for example stroke or heart failure.”

Other findings were that of the various antiarrhythmic drugs, amiodarone remained the most commonly used (around 25% of patients). Catheter ablation was used in approximately 20% of patients with paroxysmal AF.

Patients in the pilot registry will be followed up annually for 3 years. Professor Lip said: “The one year follow up data will be presented at ESC Congress 2014 and will show how management practices and outcomes have changed since the start of the pilot.”

He added: “The pilot is the prelude to the Atrial Fibrillation General Long Term Registry, which will start from October 2013 and has a much larger design. An invitation to participate has been sent to all ESC member countries.”

Professor Lip concluded: “Patients with asymptomatic AF need to be identified earlier so they can be treated to avoid complications such as heart failure and stroke. And doctors should be encouraged to use oral anticoagulation in patients with AF to avoid needless occurrences of stroke.”

[oma]

Amsterdam, The Netherlands –Tuesday 3 September 2013: EUROASPIRE IV has revealed the achievements and remaining challenges for secondary prevention in coronary patients across Europe. The latest results were presented at ESC Congress 2013 today.

The EUROASPIRE surveys are part of the ESC’s EORP programme1 and track lifestyle, risk factor control and cardioprotective drug use in Europe. Results from the 24 countries in the hospital arm of EUROASPIRE IV are presented for the first time at ESC Congress 2013. The primary care arm will be conducted next year.

Data were collected using standardised methods during May 2012 to April 2013 in 7,998 patients < 80 years with established coronary heart disease (25% women, mean age 64 years, one-third <60 years old). Patients had been hospitalised in the last years for coronary heart disease. They were interviewed and clinically examined for the study 6 months to 3 years (median 1.35 years) after the hospital episode.

The prevalence of obesity (BMI>30kg/m2) was 38% (36% of men, 44% of women). Obesity varied from between 25% and 30% in centres from Bosnia Herzegovina, the Netherlands, Serbia and Sweden to more than 45% in centres from Romania, the Russian Federation and Slovenia.

The prevalence of central obesity (waist circumference >88cm in women, >102cm in men) was 58% (53% in men, 75% in women). The range2  in women was 62-86%. Professor Guy De Backer (Belgium) said: “Obesity is more than double expected levels for this age group. We also found that 38% of obese patients had no plans for weight loss and 20% had never been told they had a weight problem.”

The prevalence of diabetes was 40%, comprised of 27% who knew they had diabetes and 13% undiagnosed but with a fasting plasma glucose >7.0 mmol/L during the study. Of those with known diabetes, 53% had HbA1c <7% meaning it was well controlled. Professor De Backer said: “In adults of that age we would expect a diabetes prevalence of 10-15% so our finding of 40% is extremely high. Among those diagnosed with diabetes,HbA1c  was uncontrolled (>7%) in less than 35% of patients in centres from Belgium and Finland to more than 55% of patients in centres from Bulgaria, Croatia, France, Turkey and the UK.

Smoking (self reported or >10ppm CO in expired breath) was found in 16% of patients (18% of men, 11% of women, 34% of <50 year olds). Of the patients who were smokers before hospitalisation 51% were still smoking 1.3 years later. Professor De Backer said: “Smoking is still a major problem especially in younger patients.”

The prevalence of elevated blood pressure (>140/90mmHg) was 39% (range 24-56%), while 11% of patients had grade 2 hypertension (>160/100mmHg). Antihypertensive drugs were used in 78% of patients (range 52-94%), of whom 58% had well controlled blood pressure (<140/90mmHg).

Some 87% of patients were taking lipid lowering drugs (almost exclusively statins) (range 75-95%). Of these, 58% had a LDL-C level of < 2.5 mmol/L (100 mg/dL) but only 21% reached an LDL-C target of <1.8mmol/L (70mg/dL). Most patients (94%) took antiplatelet drugs and 83% took beta blockers.

Most patients (94%) said they were fully (74%) or nearly (20%) compliant with their drugs. Professor De Backer said: “These findings do not confirm claims by physicians that patients are not taking the medications they are prescribed.”

Only half (51%) of patients received advice to attend rehabilitation and prevention programmes (range 0-95%), and of these 72% fully attended. Professor De Backer said: “Some countries do not have any programmes on secondary prevention and rehabilitation while in others they are standard practice. Most patients follow advice to attend such programmes so the challenge is to achieve wider implementation across Europe in all countries.”

[oma]

Amsterdam, The Netherlands –Tuesday 3 September 2013: Adverse lifestyle trends are countering improvements in cardiovascular risk factor management in coronary patients, according to results from three EUROASPIRE surveys in 1999-2013. The EUROASPIRE time trend analysis was presented today at ESC Congress 2013.

The EUROASPIRE1 surveys describe lifestyle, risk factor control and cardioprotective drug management of coronary patients in Europe. Standardised methodologies have been used in each survey which allow for comparisons over time.

A time trend analysis was conducted in the nine countries (Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, the UK) which conducted surveys II (1999-2000), III (2006-07) and IV (2012-13). A total of 12,775 consecutive patients <70 years with coronary artery disease (coronary artery bypass surgery, angioplasty or acute coronary syndromes) were included of whom 8,456 were interviewed across the three surveys ≥6 months after their initial hospitalisation.

Smoking prevalence stayed the same (21% in 1999/2000, 19.9% in 2006/7, 18.2% in 2012/13; p=0.55) and remained highest in patients <50 years. Professor David A. Wood (UK) said: “The highest levels of smoking are still in the youngest patients who have the most to gain from quitting. But the use of pharmacotherapy for smoking cessation remained low over the 14 years so more emphasis is needed in this area.”

The prevalence of obesity increased across the three surveys (31.9%, 33.3%, 38.5%; p=0.007) as did the prevalence of central obesity (50.5%, 50.5%, 57.2%; p=0.04). Average body mass index (BMI, kg/m2) increased from 28.5 (standard deviation [SD]=4.5) to 28.8 (SD=4.6) and to 29.2 (SD=4.7) kg/m² across the three surveys. Physical activity did not change over the 14 year study period.

The prevalence of diabetes increased across the three surveys (18.5%, 23.8%, 27.2%; p=0.0004). Glycaemic control in patients with diabetes remained unchanged, with only 30% of patients achieving the therapeutic threshold for fasting glucose (<7 mmol/L).

Professor Wood said: “Lifestyle trends are moving in the wrong direction. The prevalence of obesity and central obesity has increased over the three surveys and is now at its highest level. And there is a corresponding increase in the prevalence of diabetes.”

The use of cardioprotective drugs increased between surveys II and III, but there was no significant change between surveys III and IV. Professor Wood said: “We seem to have hit a ceiling on the use of cardioprotective medications. Most patients use optimal drug treatment but do not benefit fully because of their poor lifestyle.”

The prevalence of raised blood pressure dropped by 8% from survey III to IV, while the prevalence of very high blood pressure (systolic ≥160 mmHg and/or diastolic ≥100 mmHg) dropped significantly across the three surveys (21.9%, 16.8% and 12.8%; p=0.0006). Therapeutic control of blood pressure in patients using blood pressure lowering drugs improved significantly with 55% of patients below target in survey III.

The prevalence of raised total cholesterol (≥4.5 mmol/l) decreased (77.0%, 40.6%, 32.8%; p<0.0001) as did the prevalence of elevated LDL cholesterol (≥2.5 mmol/l) (78.0%, 42.9%, 33.5%; p<0.0001). The proportion of patients on lipid-lowering drugs who met the LDL cholesterol target (<1.8 mmol/L) increased even though use of these drugs stabilised between surveys II and III. However, 75.3% of patients still did not reach the target.

Professor Wood said: “Management of blood pressure and lipids has improved but again the benefits are mitigated by poor lifestyle and a growth in obesity and diabetes. Our analysis highlights the pressing need for modern preventive cardiology programmes with lifestyle change at their core and not simply writing prescriptions for drugs.”

[oma]

Amsterdam, The Netherlands –Tuesday 3 September 2013: Drug treatment for chronic heart failure (HF) is acceptable but device implantations are still too low, according to the latest findings of ESC Heart Failure Long-Term Registry. The results were presented at the ESC Congress today by Professor Aldo P. Maggioni (Italy) and also revealed large heterogeneity in treatment for acute HF.

Professor Maggioni said: “Recommendations in guidelines are referred to as ‘optimal therapy’ but the ESC-HF Pilot showed that many HF patients do not receive recommended drugs and doses.1 Previous studies have not reported the reasons why recommendations are sometimes not followed in clinical practice.”

He added: “The ESC Heart Failure Long-Term Registry, which is part of the ESC’s EORP programme2 was established to evaluate how European guidelines on pharmacological and non-pharmacological treatments for HF are adopted in clinical practice. We also collected information on the reasons for failing to give recommended treatments or dosages.”

The ESC Heart Failure Long-Term Registry is a prospective, observational study conducted in 211 cardiology centres of 21 European and Mediterranean countries. From May 2011 to April 2013, 12,440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. The results of the registry are presented for the first time today at ESC Congress 2013 and published simultaneously in the European Journal of Heart Failure.3

In patients hospitalised with acute HF, use of intravenous inotropes and nitrates was not in line with the guideline recommendations. Prescription rates of all recommended oral medications significantly increased at discharge compared to preadmission. Professor Maggioni said: “Treatment recommendations for patients hospitalised with acute AF are largely based on expert opinion, which may explain why adherence is low. But hospitalisation does provide an opportunity to improve prescription of oral medications.”

In ambulatory patients with chronic HF, renin-angiotensin system (RAS) blockers (includes angiotensin converting enzyme [ACE] inhibitors and angiotensin receptor blockers [ARBs]), beta blockers, and mineralocorticoid receptor antagonists (MRAs) were prescribed in 89.2%, 88.9% and 59.3% of cases. But when reasons for non-adherence were considered, real under-treatment occurred in 5.9%, 4.6% and 14.4% of cases. In most cases the reason for non-prescription was a contraindication or documented intolerance.

Less than one-third of patients received the recommended target dosage of these drugs: 29.3% for ACE-inhibitors, 24.1% for ARBs, 17.5% for beta blockers and 30.5% for MRAs. A reason for not achieving the target dosage was reported in almost two-thirds of the remaining cases and included intolerance and ongoing drug uptitration.

Professor Maggioni said: “When reasons for non-adherence are taken into account, drug treatment of patients with chronic HF complies acceptably with guidelines. Our results suggest that the dosages used in clinical practice may meet patient need and tolerance to drugs.”

Implantation rates of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) devices in ambulatory patients with chronic HF were analysed. The investigators found that ICD and CRT device implantation was not planned, despite being clinically indicated, in 44% and 40% of patients, respectively. The reasons for non-implantation, when clinically indicated, were doctor uncertainties on the indication, patient refusal or logistical/cost issues. Professor Maggioni said: “Device implantation rates are still too low and greater efforts are needed to increase access.”

He concluded: “Our registry reveals patchy adherence to guidelines in acute HF, acceptable use of drug treatments in chronic HF but sub-optimal use of devices. The practicalities of adhering to guidelines in daily clinical practice should be taken into account when guidelines are being written, particularly since failure to comply may have legal consequences in some countries.”

[oma]

Amsterdam, The Netherlands – Tuesday 3 September 2013: Substantial numbers of patients in particular in Eastern and Southern Europe do not receive any reperfusion therapy after ST-segment elevation myocardial infarction (STEMI), according to a Stent for Life (SFL) survey of 37 ESC countries. The problem of no reperfusion therapy was greatest in Bosnia Herzegovina, Bulgaria, Serbia and Ukraine. The full results of the survey were presented for the first time at the ESC Congress today by Professor Steen Kristensen (Denmark).

Primary percutaneous coronary intervention (PPCI) is recommended as the first choice of treatment in patients with STEMI.1 But a survey published in 2009 (based on 2007/2008 data) revealed that many STEMI patients received thrombolysis and a large group did not receive any reperfusion therapy.2

The SFL Initiative3 was established in 2008 to drive equal access to life saving PPCI in STEMI patients across Europe. A new survey, published today, reveals the status of reperfusion therapy in patients admitted with STEMI in 37 of the 53 ESC member countries. Professor Kristensen said: “We conducted the survey to identify countries that still have a low uptake of PPCI, and countries where there is a high percentage of patients not getting any reperfusion therapy.”  

This cross-sectional descriptive study was based on aggregated country level data on patients admitted with STEMI during 2010 or 2011. Data was collected on the use of reperfusion treatment and mortality, the numbers of cardiologists and the availability of PPCI facilities. Information came from national or regional registries, or from expert estimates when registries did not exist.

Overall, the survey demonstrated large variations in the management of STEMI patients in the 37 countries. During 2010 and 2011, a substantial number of STEMI patients in Eastern and Southern Europe did not receive any reperfusion therapy. These numbers were highest in Bosnia Herzegovina, Bulgaria, Serbia and Ukraine (e.g. in Ukraine this number was 526 per million inhabitants).

The number of PPCI per million inhabitants ranged from 23 in Saudi Arabia to 938 in The Netherlands. PPCI was the dominant reperfusion strategy in 33 countries but thrombolysis was still the treatment of choice in 4 countries (Bosnia Herzegovina, Cyprus, Greece and Serbia).

Professor Kristensen said: “Overall there is improvement since the last survey but there is still quite a lot of work to do in several countries. PPCI is the best therapy but if it isn’t available then thrombolysis is an acceptable option. The worst case scenario is when patients do not get any reperfusion therapy.”

All countries reported large increases since 2007/2008 in the number of catheterization laboratories providing PPCI services 24 hours a day, 7 days a week. The average population size served by a single PPCI centre with 24/7 services ranged from 31,300 inhabitants per centre in San Marino to 6,533,000 inhabitants per centre in Saudi Arabia.

As previously reported at EuroPCR, the survey reveals that PPCI use increased dramatically between 2007 and 2011 in the six countries enrolled in the SFL Initiative in 2009. During this period, PPCI use increased from 23% to 57% in Bulgaria, 33% to 64% in France, 9% to 32% in Greece, 19% to 44% in Serbia, 30% to 50% in Spain and 8% to 78% in Turkey. As PPCI use rose in the six countries, the percentage of patients not receiving any reperfusion therapy decreased.

Professor Kristensen concluded: “PPCI is the first choice of treatment in most countries but more work is needed to ensure equal access for all patients. The SFL Initiative will continue to help countries identify their own barriers to implementing guidelines (e.g. poor access to emergency health services, economic factors or lack of trained doctors) and find ways of increasing their use of life saving PPCI.”

[oma]

In this 3.5-minute video interview conducted at the ESC conference, Dr Tom K.M. Wang discusses the results of a 5-year study comparing aortic valve replacement in octogenarians and septuagenarians.

Interview with Dr Tom Kai Ming Wang - ESC 2013: Aortic valve replacement in the very elderly

Septuagenarians: Ouderen van 70 - 79 jaar
Octogenarians: Ouderen van 80 - 89 jaar

[oma]

In this 3.5-minute video interview conducted at the ESC conference, Professor Helmut Schühlen discusses the results of his study of the determinants of door-to-balloon time for STEMI patients in Berlin. This retrospective study of 5,000 patients was based on data from the Berlin MI Registry and has the ultimate aim of improving the standard of care in Berlin where most STEMI patients are not treated within the recommended 60-minute period.

Interview with Professor Helmut Schühlen - ESC 2013: Door-to-balloon time for STEMI

[oma]

Prof. Christophe Leclercq, FESC

ESC TV 2013 - Village 1: Updates on arrhythmia and device therapy

[oma]

Dr. Bhatt presented the SAVOR-TIMI 53 data at ESC 13. Here he provides his thoughts on the study.

Dr. Bhatt on SAVOR-TIMI 53