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

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European Society of Cardiology Congress 2013
Special features and activities for young cardiologists at ESC Congress 2013 in Amsterdam!

ESC Congress 2013

http://www.escardio.org/communities/cardio-tomorrow/congresses-events/Pages/esc-congress-2013.aspx

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Amsterdam, The Netherlands – Saturday 31 August 2013: HbA1c is used to diagnose diabetes in the new ESC/EASD Guidelines presented today at ESC Congress 2013 by joint Task Force Chairs Professor Lars Rydén (Sweden) of the ESC and Professor Peter J. Grant (UK) of the EASD.

The "2013 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular disease developed in collaboration with EASD," are published today on-line in European Heart Journal1 and on the ESC Website (www.escardio.org/guidelines). They were written jointly by the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD).

Previous ESC/EASD Guidelines on diabetes were published in 2007. The 2013 version introduces glycated haemoglobin (HbA1c) to diagnose diabetes. If HbA1c is elevated the patient is diagnosed with diabetes. If HbA1c is not elevated, patients with cardiovascular disease should receive an oral glucose tolerance test (OGTT). This requires fasting patients to ingest glucose and blood levels are measured before and after 2 hours.

Professor Rydén said: “We have simplified diagnosis because many patients may be disclosed with HbA1c, limiting the numbers who need the lengthier test. But a normal HbA1c does not rule out diabetes in high risk patients, who need to have an oral glucose tolerance test.”

Cardiovascular risk assessment has also been simplified and risk engines are no longer advocated. Patients with diabetes are considered at high cardiovascular risk. Patients with diabetes and cardiovascular disease (myocardial infarction, angina pectoris or peripheral vascular disease) are at very high risk of recurrent cardiovascular disease. Professor Grant said: “Risk engines which accumulate risk factors and produce a low, medium or high risk score are less useful for patients with diabetes.”

Recommendations on revascularization have undergone two major changes since 2007. In patients with stable coronary artery disease and no complex coronary lesions, medical therapy is recommended before interventions. Professor Rydén said: “In former days we were quick to do coronary interventions but based on new trial data we now do not advocate bypass surgery and coronary angioplasty until medical therapy has been tried.”

Also new is the recommendation that patients with several or complex coronary artery stenoses should be offered bypass surgery before percutaneous coronary dilatation. Professor Rydén said: “New trial data clearly shows that morbidity and mortality are superior with bypass surgery compared to coronary dilatation even with the use of drug eluting stents.”

Targets for blood pressure and glucose are now individualised. The general blood pressure target for diabetics is <140/85mmHg (in 2007 it was 130/80mmHg). In patients who also have kidney disease the target is <130/85mmHg. Control should also be stricter in patients at risk of stroke.

Glycaemic control should be carefully implemented with lower targets in young patients recently diagnosed with diabetes and untouched by cardiovascular disease. Control should be modest in older patients with longstanding diabetes and cardiovascular complications to avoid side effects.

Other changes include the prioritisation of weight stabilisation over reduction and a recommendation against drugs to increase HDL cholesterol. Aspirin is not advocated in patients with diabetes unless they also have cardiovascular disease and in this case novel platelet stabilising drugs may be more effective. A completely new chapter on patient centred care has been included which advocates shared decision making.

Professor Grant said: “Diabetes is a complex disease and it is very important that cognitive behavioural strategies are built into the treatment strategy so that the patient is empowered to take care of themselves to a large extent.”

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Amsterdam, The Netherlands – Saturday 31 August 2013: Imaging has a greater role in coronary artery disease (CAD) diagnosis in the new ESC Guidelines presented for the first time today at ESC Congress 2013 by joint Task Force Chairs Professor Gilles Montalescot (France) and Professor Udo Sechtem (Germany).

The “ESC Guidelines on the management of stable coronary artery disease” are published today on-line in European Heart Journal1 and on the ESC Website www.escardio.org/guidelinesPrevious

ESC Guidelines on this topic were published in 2006. The 2013 version gives more prominence to new imaging techniques such as cardiovascular magnetic resonance (CMR) and coronary computed tomography (CT) angiography in the diagnosis of CAD in patients with stable chest pain. The guidelines clearly define which patients should receive coronary CT angiography to avoid overuse of this technique.

Professor Sechtem said: “Another new aspect is that the diagnostic algorithm is based on pre-test probability, in line with the 2010 UK National Institute for Health and Clinical Excellence (NICE) guidelines on chest pain of recent onset. The estimation of pre-test probability is based on the latest data measuring the prevalence of coronary artery stenosis in a current large cohort of male and female patients of various ages with various clinical presentations.”

As in the 2006 guidelines, invasive coronary angiography and revascularization are recommended mainly for patients at high risk for coronary events. But the definition of risk and the methods for assessing it have been updated. The previous guideline based risk estimation solely on the stress electrocardiogram (ECG) but this has been expanded to include imaging techniques. The high risk group now begins at a slightly higher estimated annual mortality of >3%.

Professor Sechtem said: “The approach to patients with functional coronary disease, i.e. coronary vasospasm or microvascular disease, has been redefined. The definition of this group by clinical and non-invasive evaluation has become more important than in 2006 as more patients, especially females, undergo invasive coronary angiography because of stable angina and are then found to have no epicardial stenosis.”

Controlling heart rate is the new treatment goal for medical therapy in the 2013 guidelines. First line treatment should be with beta-blockers or calcium channel blockers lowering heart rate, both of which are readily available. Second line treatment includes long acting nitrates and new drugs on the market. Professor Montalescot said: “We have roughly the same level of evidence for all of the second line drugs and we recommend that physicians choose according to what is available in their country.”

He added: “Before there is any discussion about revascularization, patients should receive optimal medical therapy. The decision on the type of revascularization should then be based on a discussion between the surgeon and the cardiologist in the heart team. Moreover, revascularization should only be considered in patients with evidence of regional ischemia or a pathological fractional flow reserve (FFR).”

Professor Sechtem said: “We hope these guidelines will make practitioners dealing with patients with stable chest pain and other forms of stable coronary artery disease think more often of functional coronary disease which then should be treated appropriately. Moreover, patients at high pre-test probability do not need to undergo a battery of tests before being directed to invasive coronary angiography on clinical evidence only. Of course, revascularization in such patients should be directed by using FFR measurements liberally.”

He concluded: “We hope that overuse of coronary CT angiography will be discouraged by the clear definition of a patient group at the lower range of intermediate pretest probabilities in whom this technique may be helpful for excluding stenoses.”

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'Clinical cases for practitioners' concludes. Resources from the session will be available at http://www.escardio.org/365

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Amsterdam, The Netherlands – Saturday 31 August 2013: Eight weeks of smoking cessation reverses the endothelial damage caused by smoking, according to research presented at the ESC Congress today by Dr Yasuaki Dohi from Japan. Serotonin remained elevated, suggesting 8 weeks of cessation is insufficient to reverse the risk of myocardial infarction.

Dr Dohi said: “Smokers are twice as likely to have a heart attack as people who have never smoked. Quitting smoking is the most important thing people can do to reduce their risk of cardiovascular disease. But until now, studies have not examined whether the increased risk caused by smoking is completely reversed after smoking cessation.”

The current study investigated how the vascular system is altered by smoking and whether the changes can be normalised by smoking cessation. The researchers focused on the effects of smoking and smoking cessation on arterial endothelial function and circulating serotonin concentration.

Both endothelial dysfunction and serotonin contribute to the development of atherosclerosis. Serotonin released from platelets induces platelet aggregation, which initiates blood coagulation and contractions in arteries especially those with damaged endothelium.

Smoke from cigarettes contains toxic molecules including nicotine, carbon monoxide and hydrogen cyanide which may cause and promote atherosclerosis via endothelial dysfunction and increased activity of blood coagulation.

The study included 27 apparently healthy male smokers aged 40±8 years and 21 age-adjusted non-smokers (40±7 years). Endothelial function was assessed by flow mediated dilation and peripheral arterial tonometry (PAT). Both methods assess endothelial function as the ability to dilate arteries through the release of endothelium-derived relaxing factors.

Dr Dohi said: “As expected, smoking damaged arterial endothelial function and increased plasma serotonin levels.”

Only 21 subjects agreed to stop smoking for 8 weeks. Smoking cessation was confirmed in 11 out of the 21 subjects by measuring serum levels of cotinine, the principal metabolite of nicotine. Smokers who completely attained smoking cessation had a significantly increased PAT ratio (P<0.05) but serotonin levels were not significantly changed (see figure). Dr Dohi said: “This indicates that endothelial function had improved after 8 weeks of smoking cessation but serotonin levels remained at dangerously high levels.”

An analysis of all 21 subjects who tried to stop smoking showed that serotonin levels were positively correlated with serum levels of cotinine (152±140 ng/ml, r=0.45, P<0.05) and inversely with PAT ratio (endothelial function: 0.25±0.10, r=-0.45, P<0.05). Dr Dohi said: “These results show that smoking cessation may have a beneficial effect on serotonin levels, but this effect is too small to normalise serotonin levels within 8 weeks. It will take a long time to see a significant effect on serotonin levels after smoking cessation.”

Dr Dohi concluded: “Short term smoking cessation only partially improved the undesirable alterations caused by smoking. After 8 weeks of no smoking endothelial function improved but plasma serotonin remained high, suggesting that patients are still at increased risk of cardiovascular disease. Further studies are needed to see if longer term smoking cessation can completely reverse the damage caused by smoking.”

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Amsterdam, The Netherlands – Saturday 31 August 2013: Smokers who survive to 70 still lose an average of 4 years of life, according to findings from the Whitehall study presented at ESC Congress 2013 today by Dr Jonathan Emberson from the UK.

Dr Emberson said: “Despite recent declines in the numbers of people smoking and tar yields of cigarettes, smoking remains the leading preventable cause of death in Europe.”

He added: “Previous studies had demonstrated that prolonged cigarette smoking from early adult life was associated with about 10 years loss of life expectancy, with about one quarter of smokers killed by their habit before the age of 70. Stopping at ages 60, 50, 40 or 30 years gained back about 3, 6, 9 or the full 10 years. However, the hazards of continuing to smoke and the benefits of stopping in older people had not been widely studied.”

In the current study, scientists tracked the health of 7,000 older men (mean age 77 years, range 66 to 97) from 1997 to 2012 who took part in the Whitehall study of London civil servants. Hazard ratios (HRs) for overall mortality and various causes of death in relation to smoking habits were calculated after adjustment for age, last known employment grade and previous diagnoses of vascular disease or cancer.

During the 15-year study 5,000 of the 7,000 men died. Deaths in current smokers were about 50% higher than in never smokers (HR=1.50), due chiefly to vascular disease (HR=1.34), cancer (HR=1.74) and respiratory disease (HR=2.39).

Deaths in former smokers were 15% higher than in never smokers (HR=1.15), due chiefly to cancer (HR=1.24) and respiratory disease (HR=1.58). Compared with never smokers, men who had quit smoking within the previous 25 years (median 14 years) had a 28% higher mortality rate (HR=1.28) while men who quit >25 years ago (median 35 years) had no significant excess risk (HR=1.05).

Dr Emberson said: “Our results clearly show that active smoking continues to increase the risk of death in old age. Risk in former smokers decreases as the time since quitting gets longer and, if one survives long enough, eventually reaches levels of never smokers.”

Average life expectancy from age 70 was about 18 years in men who had never regularly smoked, 16 years for men who gave up smoking before age 70 but only about 14 years in men still smoking at age 70. Two-thirds of never smokers (65%), but only half of current smokers (48%), survived from age 70 to age 85.

Dr Emberson said: “This study shows that even if you were to ignore all the deaths caused by smoking before the age of 70, older smokers still do considerably worse than older non-smokers, losing a considerable amount of subsequent lifespan.”

Dr Robert Clarke (UK), coordinator of the study, concluded: “We have shown that even if a smoker is fortunate enough to survive to age 70 they still lose, on average, about 4 years of subsequent lifespan compared with men who do not smoke. Quitting is beneficial at any age and it really is never too late to stop.”

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Amsterdam, The Netherlands – Saturday 31 August 2013: STEMI incidence fell in Southern Switzerland after implementation of the smoking ban in public places, reveals research presented at the ESC Congress today by Dr Alessandra Pia Porretta from Switzerland.

Second-hand smoke increases the risk of coronary artery disease and acute myocardial infarction. For this reason, health policies aimed at reducing tobacco consumption and public smoke exposure are strongly recommended.

Dr Porretta said: “Canton Ticino (CT), which is one of the 26 cantons of the Swiss Federation, was the first Swiss canton to introduce a smoking ban in April 2007. We had the opportunity to assess the long-term impact of the smoking ban on the incidence of ST-segment elevation myocardial infarction (STEMI) and to compare STEMI epidemiology with Canton Basel City (CBC), where the law was not yet implemented.”

The principal investigator of the study (Dr Marcello Di Valentino) collected data retrospectively from the codified hospital discharge registry (ICD-10 codes) on STEMI hospitalisations in CT and CBC during the 3 years before (2004-2007) and after (2007-2010) the ban was implemented in CT.  

In CT, data were acquired from the four cantonal public hospitals and from Cardiocentro Ticino, an exclusive institution for invasive coronary interventions. In CBC, data were obtained from the public University Hospital of Basel. For each considered year, STEMI incidence per 100,000 inhabitants was calculated for both CT and CBC using demographic data from the Swiss Federal Statistical Office.

The study found a significant and long-lasting reduction in the incidence of STEMI hospitalisations in the overall population of Canton Ticino after the smoking ban was implemented. Incidence reduced by an average of 21.1% between 2004-07 and 2007-2010. Compared to 2004-2007, incidence reduced by 23% in 2007-2008, 15% in 2008-2009, and 24% in 2009-2010 (see figure 1A).

When population subsets were analysed, the researchers found that the significant and long-lasting reduction in STEMI admissions was observed only among older people, with a 27.4% post-ban decrease in women ≥65 years and a 27.3% reduction in men ≥65 years. Younger people (<65 years) of both sexes showed a reduction (statistically significant in men, near to significance in women) in STEMI admissions only in the first year after the ban was enforced, with no significant decrease in the second and third years (see figure 1B).

Dr Porretta said: “The varying impact of smoke-free legislation between age groups may be explained in part by the different role played by passive and active smoking in younger and older people.”

In CBC there was no change in the overall population incidence of STEMI between 2004-2007 and 2007-2010. When age and sex-standardised values were analysed, the researchers found a significant decrease in STEMI admissions in men ≥65 years old in each of the 3 years after CT’s smoking ban was implemented.

Dr Porretta said: “This could be due to ban-independent changes in the smoking habits of male smokers. Previous studies have shown that men ≥65 years make up the highest proportion of former smokers. Targeted treatment and prevention efforts towards this high risk STEMI group may also have had an impact.”

She concluded: “Introduction of the smoking ban in public places induced a significant and long-lasting reduction in the incidence of STEMI among the overall population of Canton Ticino in Switzerland. The greatest impact was seen in women ≥65 years old.”

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Teaser - Best of ESC Congress 2013

http://www.escardio.org/bestofesc2013

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Prof. Bernard Lung, FESC / Prof. Andre Keren, FESC

ESC TV 2013 - Village 6: Left and right percutaneous interventions

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Amsterdam, The Netherlands – Saturday 31 August 2013: Statins lower the rate of cataract by 20%, according to research presented at the ESC Congress today by Professor John B. Kostis from New Jersey, USA. The risk of cataract was reduced by 50% when treatment was initiated in younger individuals (in their 40s) and the duration of therapy was longer (e.g. up to 14 years).

Cataracts are the leading cause of visual impairment worldwide affecting more than 20 million people. Statins are among the most commonly prescribed medications. In the USA they are prescribed to 1 in 3 people over 45 years of age at a cost of $35 billion annually.

Professor Kostis said: “There is persistent concern among physicians and other health care providers about the possible cataractogenicity of statins.1 We therefore investigated the relationship of statins and cataracts in a meta-analysis of 14 studies selected after detailed review of the medical literature. To our knowledge this is the first meta-analysis on the topic.”

The meta-analysis included 2,399,200 persons and 25,618 cataracts. The average duration of treatment was 54 months and average age was 61.

Using random effects meta-analysis, a statistically significant decrease in cataracts with statins was observed (odds ratios [OR] 0.80, 95% confidence interval [CI] 0.77-0.83, p<0.0001). Professor Kostis said: “This corresponds to an approximately 20% lower rate of cataracts with statin use compared to no statin use.”  

Absolute risk reduction was 1.4%+0.015% (95% CI 1.1%-1.7%, p<0.0001). Professor Kostis said: “This equates to 71 persons needed to treat (NNT) with statins to prevent one cataract (95% CI 59-91 persons).”

Meta-regression showed that younger people were more likely to benefit, with an OR of 0.50 for patients in their 40s and an OR of 0.90 for patients in their 70s. Professor Kostis said: “Our analysis shows that people in their 40s who use statins have a 50% lower chance of getting cataracts. For people in their 70s risk is lowered by just 10%. It is possible that the two processes (aging and statins) work in parallel or interactively.”

The analysis showed an increase in benefit of statins with longer duration of treatment with the OR varying from 0.90 for a treatment duration of 6 months (a 10% reduction in risk) to 0.45 for a treatment duration of 14 years (a 55% reduction in risk).

There was no difference between studies by gender. Several sensitivity analyses confirmed the results.

Professor Kostis concluded: “This meta-analysis indicates a statistically significant and clinically relevant protective effect of statins in preventing cataracts. The effect is more pronounced in younger patients, and with longer use. Our findings dispel worries about the safety of statins when it comes to cataracts, and lends additional support to long term statin use.”



Figure notes:
Extraction: Studies pertaining to removal of cataract by an operation; No Extraction: Studies where removal of cataract by an operation was not the endpoint; Clinical: Studies where the patient or a physician reported the presence of cataract; Opacities: Studies where an ophthalmologist reported the presence small areas of cloudiness in the lens of the eye unrelated to visual complaints by the patients.