TUESDAY 2 SEPTEMBER B A R C E L O N A 2 0 1 4

Plan your day with the Less may be ‘ESC 2014’ Mobile App Biodegradable stent more in technology moves on cathether TOTAL ATTENDANCE Ultra-thin platform DES non-inferior ablation for AMSTERDAM 2013 to standard in BIOSCIENCE trial persistent AF 29 982 Catheter ablation of the pulmonary BARCELONA 2014 30 288 veins alone can improve outcomes in around half of those with persistent atrial fibrillation, suggests the STAR Don’t Miss AF 2 trial presented at a Hot Line • 08:30 - 18:00 Brussels - Central Village yesterday. The study also found that Mobile App Interactive Sessions throughout the Villages, patients did not benefit from further Cases in Crossfire, Meet the Experts, Guidelines ablation because it increased treatment in Daily Practice time and did not reduce AF recurrence. • 08:30 - 18:00 Brussels - Central Village Investigator Atul Verma from Global Focus Sessions Live & Recorded cases Southlake Regional Health Centre, in • 08:30 Barcelona - Central Village Newmarket, Canada, said: ‘Pulmonary ESC/ESA Guidelines on non-cardiac surgery: cardiovascular vein isolation alone achieved assessment and management reasonable success rates which were • 08:30 Helsinki - Central Village quite comparable to prior published Registry Hot Line: Valves and heart failure success rates in paroxysmal AF, so • 10:00-11:00 Tel Aviv - Village 9 this may be an effective strategy for ESC General Assemblies patients with persistent AF.’ • 10:10 Brussels - Central Village The STAR AF 2 results may ‘force’ What are the editor’s criteria for good scientific papers? a change in guideline thinking, added • 11:00 Barcelona - Central Village Verma, and a shift in practice to Hot Line: Coronary artery disease and atrial fibrillation Thomas Pilgrim: ‘Our findings document excellent clinical outcomes for both stent types in a shorter and more effective pulmonary • 14:00 Barcelona - Central Village patient population with minimal exclusion criteria.’ vein ablation without the addition of ESC Guidelines on pulmonary embolism other ablation. • 14:00 Brussels - Central Village February 2012 and May 2013 to treatment Pulmonary vein isolation (PVI) is Clinical Trial Update Hot Line: Stable CAD and atrial fibrillation HOT LINE SESSION with the biodegradable sirolimus-eluting considered the cornerstone of catheter • 16:30 Barcelona - Central Village stent (1063 patients, 1594 lesions) or the ablation in AF patients. And in order Clinical Trial Update Hot Line: Infarction, interventions and outcome RESULTS durable everolimus-eluting stent (1056 to improve outcomes, guidelines patients, 1545 lesions). suggest that ‘more extensive’ ablation • 16:30 Brussels - Central Village

The single-blind investigator initiated is required in addition to PVI.. ESC Cardiology Quiz study, in which patients and outcome In what was the largest trial of An ‘ultra-thin’ biodegradable polymer assessors were masked to treatment its kind, the STAR AF 2 study sirolimus-eluting stent has been found non- allocation, took place in nine hospitals in randomised subjecs to PVI alone, PVI inferior to the standard durable polymer Switzerland. The primary endpoint, target plus ablation of complex electrograms, everolimus-eluting stent for target lesion lesion failure, was a composite of cardiac or PVI plus ablation of linear lesions in EXPLORE OUR EXCLUSIVE failure, according to the BIOSCIENCE death, target vessel myocardial infarction, the left atrium. CARDIO-ZINE TODAY study reported yesterday in a Hot Line and clinically-indicated target lesion The study findings showed that session. The ‘all comers’ trial, published revascularisation at 12 months. successful PVI was achieved in 97% of simultaneously in The Lancet, revealed a Results showed that target lesion failure all patients with no differences between benefit for the biodegradable stent in the occurred in 6.5% (69 cases) receiving groups. However, procedural time was subgroup of patients with ST-elevation the biodegradable polymer sirolimus- significantly shorter for the PVI alone www.oup.com/esc14 myocardial infarction. eluting stent compared to 6.6% (70 cases) group (167 minutes) compared to the Biodegradable polymers have been receiving the durable polymer everolimus- PVA plus electrograms and PVI plus Download the introduced to overcome concerns over eluting stent (absolute difference -0.14%, p lines groups (229 and 223 minutes EHRA the delayed arterial healing which might for non-inferiority <0.0004). respectively, p=<0.001). KEY MESSAGES result in very late stent thrombosis and In the subgroup with STEMI (who The primary outcome of the trial Mobile app restenosis. However, studies comparing the comprised 20% of patients), target lesion was not statistically different between current standard of thin strut stents with failure occurred in 3.3% receiving the the three study arms at 18 months. Tunewwww.escardio.org/EHRA into the latest science biodegradable stents have been scarce. biodegradable stent and 8.7% receiving the Thus, the BIOSCIENCE study aimed durable polymer everolimus-eluting stent. to compare the performance of the new ‘Our findings document excellent ultra-thin strut, biodegradable polymer- clinical outcomes for both stent types in a based sirolimus-eluting stent (Orsiro) with patient population with minimal exclusion the standard durable, thin-strut, polymer- criteria – a substantial proportion of whom based everolimus-eluting stent. The presented with acute coronary syndromes www.escardio.org/esc2014 biodegradable sirolimus-eluting stent had a and complex lesion characteristics,’ write strut thickness of 60 µm, while the durable the authors. ‘The biodegradable polymer everolimus eluting stent had a thickness of sirolimus-eluting stent matched the 81 µm. outcomes of one of the safest and most In the study, presented yesterday by effective new generation stents.’ Thomas Pilgrim from the University In an ESC press briefing Pilgrim said: Hospital Bern, 2119 patients with 3139 ‘The observed benefit in the subgroup lesions were randomly assigned between Continued on page 2 Atul Verma: Results from STAR AF 2 study.

www.escardio.org #ESCcongress 2 Financial cost of telemonitoring Left or right vagus ICD use no higher than office cost nerve stimulation The costs of moving to telemonitoring for ICD patients in HFrEF patients varies widely across Europe, according to the EuroEco study presented at a Hot Line session yesterday. The study, published Chronic open loop autonomic regulation therapy (ART) simultaneously in the European Heart Journal, found delivered to either the right or left vagus nerve was found that, while total insurance costs are no different, national to be feasible and well tolerated in the ANTHEM-HF study differences in reimbursement may prove insurmountable in which 60 reduced ejection fraction HF patients were barriers to adoption. randomised to a vagus nerve stimulator device implanted on Principal investigator Hein Hiedbuchel from the Heart the left or right of the heart. To determine the best tolerated Center Hasselt, Belgium, hoped study results would intensity, stimulation was titrated over a 10 week period emcourage ‘balanced reimbursement scenarios’ for moves to assess improvement in LV structure and function, and towards remote monitoring-based care. symptom burden in patients with chronic stable HF enrolled While telemonitoring for ICD patients has been available into the study. for a decade, no trial until now has provided cost analysis data The study was performed at ten sites in India and results from the provider viewpoint. Now, however, the EuroEco presented by Inder Anand from the University of Minnesota study does provide a financial assessment of the impact of the Medical School found 10 serious adverse events on the left cost differential between home-monitored follow-up and no and 11 on the right; 82 non-serious adverse events were home monitoring. reported for those receiving left VNS and 91 right VNS. A total of 303 patients were recruited at 17 centres in Hein Hiedbuchel: The first study to assess the financial Results at six months found the average increase in LVEF Belgium, Germany, Britain, Spain and the Netherlands. impact of telemonitoring ICD patients. from baseline was 4.5%, and that left ventricular end systolic All were scheduled to receive a new or replacement single volume decreased by -4.1 mL. The NYHA class of 77% of or dual-chamber ICD equipped with home telemonitoring to home monitoring (HM ON) or no home monitoring (HM patients improved from baseline. technology. After ICD placement, patients were randomised OFF)) and followed for two years. The HM OFF group had ‘The results of the ANTHEM-HF study demonstrate that routine in-office visits scheduled throughout the study. autonomic regulation therapy using chronic low-amplitude Time expenditure was tracked for all physician, nurse vagus nerve stimulation is feasible on the left or right side,’ Continued from page 1 and technician contact with patients, including phone calls said the authors, and well tolerated in patients with reduced and web-based reviews. Resource use was converted into ejection fraction. BIOSCIENCE: ultra-thin DES monetary values using country-specific cost parameters. A of patients with STEMI warrants confirmation in total of 242 patients completed the study as planned, with appropriately designed studies.’ premature discontinuation mainly related to death. In an accompanying editorial in The Lancet, Julinda Results not surprisingly showed fewer clinic visits in the Mehilli and Steffen Massberg from the Ludwig- HM ON group (3.79 vs 5.53), more non-office based contacts Maximilians University, Munich, noted that the polymer in (1.95 vs 1.01), more internet sessions (11.02 vs 0.06), and more the Orsiro stent disappears after the first two years, leaving in-clinic discussions (1.84 vs 1.28). There were also fewer behind a bare metal stent in the coronary arteries for the hospitalisations (0.67 vs 0.85) and length of stay was shorter rest of the patient’s life. (6.31 vs 8.26,) in the HM ON group. ‘It seems that, with the newer generations of thin-strut Overall, there was no difference in total follow-up cost for drug eluting stents, the maximum reduction in adverse providers between the telemonitoring and no telemonitoring events achievable by metallic scaffold improvement has groups (mean 204 euro vs 213 euro, respectively) and no already been reached. The large body of accumulated difference in the net financial benefit to providers (408 euro scientific evidence including the important results from vs 400 euro). But there was uniformity and a less favourable BIOSCIENCE, should trigger research efforts and balance for providers in those countries without any specific economic resources to focus on functional restoration follow-up reimbursement, and maintained or increased of the stented coronary artery, for example, with fully financial benefit in those countries like Germany and the UK Inder Anand: Vagus nerve stimulation feasible on either bioresorbable vascular scaffolds. where such reimbursement does exist. the left or right side. A wealth of opportunities for young cardiologists The ESC young community (under 36-year old) represents the ESC’s future. Founded in 2010 with the Cardiologists of Tomorrow, its number increases year on year. They are all embedded in different ESC Constituent Bodies. Currently eight ESC young groups are supporting a broad range of cardiology fields of expertise.

In 2014, more than 500 young cardiologists and three other finalists will each receive  Cardiologists of Tomorrow (CoT) help  Young ACCA helps spreading Acute benefited from free ESC Congress 2014 1000 euro. young health professionals network with Cardiovascular Care Association’s mission to registration, thanks to Cardiologists of  The Scientists of Tomorrow also held peers across Europe and beyond, and keep the young generation, ensures collaboration Tomorrow (CoT). their first dedicated programme in Basic them informed about the latest medical with existing young groups and promotes By joining one of the sub-specialty Science this year. advances. It is also the central link between young excellence in the acute cardiovascular young groups, young cardiologists and Young cardiologists and scientists can young groups within the Constituent care field. scientists can benefit from share knowledge and receive regular Bodies and the National Cardiac Societies  Courses and webinars updates on all the latest initiatives for the  EHRA Young EP, dedicated to throughout Europe. No membership.  Awards, prizes and grants. (Applications young community through digital tools electrophysiologists in training or no more for ESC training and research grants open such as:  Scientists of Tomorrow (SoT), than three years out of training, promotes on 15 September. For example, the Heart  LinkedIn groups composed of young basic scientists and their work and creates a global network Failure Association of the ESC is offering  Dedicated young webpages on the ESC clinical researchers, contribute to scientific, within the scientific EP community to assist 24,000 euro for a one year project to website educational and advocacy activities of the with non-¬clinical professional training successful applicants, which will enable  My ESC Young Community, the free ESC under the umbrella of CBCS. needs. them to develop their academic skills.) quarterly e-newsletter (sign up for next  EACVI Club 35 accompanies young  Young Thrombosis Researchers  Discount rates for sub-specialty issues by logging in to your account My professionals in the early stages of their Group facilitates international networking, congresses, courses, etc. ESC on www.escardio.org) careers and enhances their position within thereby strengthening the opportunities for At the ESC Congress 2014 two special the Cardiovascular Imaging Community. international collaboration and provides tracks have been designed specifically member benefits, including grants, for young cardiologists and scientists in  EAPCI Young, dedicated to young mentoring opportunities and international training: interventional cardiologists, provides an thrombosis meetings.  The ESC Cardiologists of Tomorrow educational response and offers networking track provides young cardiologists with resources for fellows still working through  Heart Failure Specialists of Tomorrow some of the most relevant and up-to-date their training in interventional cardiology or is about to be created by the Heart Failure information on key areas in cardiovascular young interventionists at the early stages of Association. Declare your interest on ESC medicine. The best case selected by the their career. Young Community Corner (ESC Stand). nucleus of CoT will win a 2000 euro prize

www.escardio.org #ESCcongress 3 New ESC guidelines on pulmonary embolism recurrence over the following ten years. Furthermore, decompensation occurs. Therefore, it may be that overall risk incomplete resolution of PE may lead to the development of can be minimised with a strategy of initial anticoagulation chronic thromboembolic pulmonary hypertension, with an and rescue fibrinolysis for hemodynamic decompensation. estimated prevalence of 0.1-4.0% after two years. The guidelines have revised the multiple therapeutic modes Current guidelines emphasise the importance of early that exist for both the acute and long-term management of risk stratification in the prognostic heterogeneous group patients with PE. Development of new oral anticoagulants of normotensive patients with acute PE. In these patients, simplifies the acute-phase treatment of most cases, and now prognostic information appears valuable for guiding two oral agents can be used as monotherapy, avoiding the management decisions - such as close monitoring and the need for low-molecular-weight heparin. According to the by Cetin Erol David Jimenez administration of thrombolytic therapy or the performance new guidelines, selected patients with PE can be treated Ankara University University of Alcalá de of other recanalisation procedures. Moreover, accurate in the acute phase as outpatients, a decision dependent on Turkey Henares, and objective models of prognosis could help clinicians prognosis and severity of PE. and Madrid, Spain to determine the suitability of early hospital discharge or In general, PE patients require three months of treatment ESC GUIDELINES on the management of patients complete ambulatory treatment of selected patients with PE with anticoagulants, with options including LMWH, with pulmonary embolism (PE) have been released and a low clinical risk. vitamin K antagonists, or direct oral factor Xa or factor during this congress and provide clinicians with a user- The new guidelines have updated the classification of PE IIa inhibitors. Thereafter, decisions for further treatment friendly summary of current evidence in the field. There severity and now take into consideration both the PE-related are based on balancing the risk of recurrence, determined are essentially three important changes in their clinical risk and the patient’s clinical status and co-morbidity. by etiology of the PE (transient risk factors, unprovoked or recommendations. First, they strengthen the case Furthermore, the authors have included for the first time cancer associated), against the risk of major haemorrhage for risk stratification in the selection of a patient-centered recommended risk-adjusted from treatment. Experience with new oral anticoagulants as treatment strategy, and are much clearer about who the therapeutic strategies on the acute, long-term, and extended therapy options is limited as intermediate-risk PE patients are. Second, the guideline basis of this classification. yet, but as a class they appear to be safe and effective for all committee evaluated outcome data from several recent trials For intermediate-risk phases of treatment. and provided recommendations on the use of thrombolytics PE patients, the new guidelines The guidelines attempt to define practices that meet the in normotensive PE patients. A third change, which is also do not routinely recommend needs of most patients in most circumstances. The ultimate very important, reflects the great number of studies with systemic thrombolysis as judgment about a particular patient must be made by the new oral anticoagulants from the past few years. As a result, primary treatment. The data clinician and patient in light of all the circumstances. the guidelines include an expanded section on these drugs in from recent trials show the both the acute and long-term settings. relative safety 2 September, 14:00-15.30 PE is associated with significant morbidity and mortality. of withholding Barcelona - Central Village As many as 15% of all patients suffering PE die within the fibrinolysis ESC Guidelines on pulmonary embolism. What is new? first month, and of those who do survive, 30% will develop unless hemodynamic What has changed?

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SATELLITE SYMPOSIUM Cairo – Village 4 / September 2nd (Tue), 12:45 – 13:45 Cardio-Ankle Vascular Index – CAVI Establishment of a New Global Arterial Stiffness Index

CHAIRMAN CO-CHAIR Prof. Roland Asmar Prof. Magnus Bäck Foundation-Medical Research Institutes Karolinska University Hospital, Sweden Switzerland & Hôpital Hôtel Dieu, France

Speakers Prof. Kohji Shirai Prof. Athanase Benetos Toho University, Sakura Medical Center, Japan University Hospital of Nancy, France “Principles of the Cardio-Ankle Vascular Index “Role of Metabolic Factors on Vascular Aging: and its Clinical Utilities.” The European Multicenter Triple A Study.” Prof. Bryan Williams Prof. Giuseppe Schillaci University College London, UK University of Perugia,Italy “Needs to Evaluate Arterial Stiffness and “Arterial Stiffness & the Heart – a Cross-talk” Central BP ”

Cardio- A nkle Vascular Index

www.escardio.org #ESCcongress 4 Far-reaching programme of ESC registries SINCE ITS INTRODUCTION in 2008 the ESC’s registry programme - known as the EURObservational Research Programme, or EORP - has grown from just two pilot surveys (both in heart failure) to a broad- ranging and far-reaching programme of 13 registries arranged within the categories of ‘General’, ‘Sentinel’, ‘Special’ and ‘Prevention’ (the last of which now includes both arms, hospital and primary care, of the latest round of the Euroaspire data collection and analysis). Back in 2008, the ESC’s then President Roberto Ferrari declared that the aim of EORP was ‘to provide a better understanding of cardiology practised in Europe based on data collected with a robust methodology procedure and to establish a professional research centre based at the European Heart House’. He added that the data should be representative of both community and setting (and independent of commercial interests), and that patients should be enrolled consecutively. Today, Ferrari will introduce a Special investigator who will present an update information about patients presenting countries with developing services - to look Session on ESC registries which reviews the this afternoon, said: ‘Management of blood with a diagnosis of ST elevation MI,’ not just at descriptors but also at surrogates progress of EORP so far and gives space to pressure and lipids has improved but the said Birmingham, UK, cardiologist Peter of quality of care such as door-to-balloon some of the programmes latest acquisitions. benefits are mitigated by poor lifestyle and a Ludman. ‘We want to look at practice times in primary PCI. It’s a move from Euroaspire in particular, has already growthtest in eorp obesity 150x105.indd and diabetes.’ 29 patterns and current treatment strategies simple provision to assessment23/07/2014 of quality.’ 09:58 fulfilled one of the basic objectives of EORP Other EORP introductions include including adjunctive technologies and drugs The pilot registry will include data from - to monitor adherence to guidelines. The the Long-Term Cardiomyopathies and used. One motivation is to try to support 13 countries, and comprise patients with latest round of data gathering, Euroaspire Myocarditis Registry, whose aim is STEMI onset within 24 hours and in the IV, showed unequivocally that in secondary to collect data on a range of relatively community. Recruitment will last three prevention patients were well below targets uncommon disorders so far unavailable months, with follow-up for one year. in obesity, diabetes, hypertension and in Europe. Most information about ‘Results should reflect patterns of smoking. For example, results based on data the presentation and natural history of diagnosis, patterns of therapy, aspects of gathered from almost 8000 patients with individual cardiomyopathies comes from techniques, use of adjunctive therapies, CAD in 24 countries showed that obesity cohort studies in a few centres in Europe and antithrombotic regimens, culprit-only prevalence was more than double expected the USA. Results of a one-year pilot study versus full revascularisation approaches, levels and that 38% of obese patients had from the ESC registry will be presented in reasons for not using guideline therapies, no plans for weight loss (indeed, 20% had today’s Special Session. and then outcome - initially to hospital never been told they had a weight problem!). Also explained will be the rationale discharge and then to one year,’ Ludman A time trend analysis of Euroaspire data for a new ESC registry in acute coronary told Congress News. - in nine countries from the first collections syndromes, which will be categorised as a of 1999 to the most recent of 2012 - found ‘General’ registry alongside Heart Failure, 2 September, 15:40-16:20 lifestyle trends ‘moving in the wrong Atrial Fibrillation and the pilot registry on Helsinki (The Hub) - Central Village direction’, with obesity now at its highest Chronic Ischemic Cardiovascular Disease. Peter Ludman: ‘We want to look at practice ESC registries level. David Wood, the study’s principal ‘The aim of this new registry is to provide patterns and current treatment strategies.’ Bioresorbable scaffolds: going but here to stay? BIORESORBABLE scaffolds (BRS), hailed as the fourth disease and those requiring multivessel revascularisation, revolution in coronary interventions, are emerging as a represent attractive candidates for BRS. dominant force in percutaneous coronary procedures and ‘The key is to undertake good lesion preparation, to seem here to stay. Speakers in a Symposium today will be methodical and check that the stent is well implanted explore the use of this new technology outside clinical trials. with optical coherence tomography, or with intravascular ‘Stents should be viewed as facilitating the healing ultrasound,’ says Colombo. ‘One tip is that, when you start process,’ says Antonio Colombo, from San Raffaele Hospital, using BRS in complex lesion, you may need to be more Milan. ‘Just as there’s no need for plaster casts to be in place aggressive with antiplatelet therapy.’ after bones have healed, so we’ve come to appreciate there’s Imaging, Nick West will explain, is important with no need for stents after arteries have healed.’ BRS for accurate sizing and checking the expansion and To date, two BRS have achieved CE marks in Europe (the apposition of the stent and defining wall characteristics. Absorb everolimus-eluting BRS from Abbott Vascular and ‘Our studies have shown that BRS don’t optimally expand DESolve, the novolimus eluting BRS from Elixir Medical), or appose to vessel walls where there are calcified plaques, with at least ten or more in development. with the consequence that we avoid using them in such Use of BRS offers an advance since it reduces future areas,’ says West, from Papworth Hospital, Cambridge, UK. adverse events attributed to the permanent presence of ‘It promises the ability to translate mechanical forces into Due to its higher resolution and ability to visualise materials in the vessel wall. New coronary plaques at the site chemical signals, such as nitric oxide release, says Gori, polymeric composition and individual struts, he adds, OCT of stent placement (defined as neoatherosclerosis) have been from Gutenberg University, Mainz, Germany. should be the imaging modality of choice. ‘Undoubtedly related to the presence of permanent foreign bodies. The BRS, he adds, now represent his personal stent of choice there’s a learning curve regarding optimal deployment of BRS approach is considered valuable for younger patients when treating ACS patients. ‘Much of the current experience BRS,’ says West. ‘I favour using OCT in the early stages of because it maintains access for future bypass surgery, and is in elective procedures, but I feel it makes good sense to introducing BRS programmes but believe it may be overkill offers possibilities for repeated percutaneous treatment use BRS in ACS. What we want to achieve is healing of the for experienced operators.’ Studies, he adds, are currently without addition of further permanent metallic layers. plaque, so patients are less likely to suffer repeat events.’ underway exploring whether long term outcomes improve Above all, Tommaso Gori will suggest in this morning’s For complex lesions use of BRS has been limited by with OCT use, and whether it is cost effective. Symposium that BRS liberate the arterial vessel to act reduced deliverability caused by increased strut thickness physiologically as a living entity, restoring pulsatility, cyclical compared to drug-eluting stents. Patients with complex 2 September, 08:30-10:00, Budapest - Village 5 strain, physiological shear stress and mechanotransduction. disease, Colombo proposes, such as long segments of diffuse Bioresorbable scaffolds – disappearing but here to stay?

www.escardio.org #ESCcongress 5 eLearning, professional unity and accreditation among new ESC President’s top priorities FAUSTO PINTO, who becomes President of the ESC later constituent bodies,’ says Pinto. today, says plans to strengthen the accreditation systems To increase the ESC’s outreach and impact, he adds, it in cardiology, the ESC eLearning platform and the role of will be important to strengthen the role of the Affiliated the Society in Brussels will be high on his agenda. Societies and societies outside the ESC family. ‘For this I Above all, Professor Pinto told ESC Congress News, intend to promote our International Affairs Department he wants to preserve the unity of the ESC and expand such that the ESC becomes the main reference for membership. ‘The ESC is unique in the sense that it education, guidelines, and registries around the world.’ gathers the whole cardiovascular community together under its umbrella, while at the same time providing Unified accreditation in the platform for the different groups and sub-specialties to develop their own activities autonomously,’ says cardiology is of Professor Pinto, who holds a chair in cardiology at Lisbon University Medical School. ‘The fact they come together fundamental importance as the ESC provides greater bargaining power. We call it the European miracle.’ Other initiatives will include a boost to the standing Professor Fausto Pinto:‘Why should patients accept treatment by Providing a unified accreditation scheme for of basic science in the ESC, with Lina Badimon, chair doctors unless they’ve the confidence in knowing they’ve achieved pre-defined levels of proficiency.’ cardiologists across the cardiovascular curriculum in of the Council on Basic Science, joining the ESC Board, Europe, he maintains, will be of fundamental importance. and establishment of a new task force on Women in life expectancy and well-being,’ he says. ‘Why should patients accept treatment by doctors unless Cardiology. The Cardiologists of Tomorrow initiative, At Lisbon University Medical School, where he has they’ve the confidence in knowing they’ve achieved pre- started a few years ago, he adds, remains essential to developed a world renowned programme of research, defined levels of proficiency and undertaken minimum guarantee the Society’s future. Professor Pinto’s interests include the assessment of numbers of procedures,’ asks Pinto. Equally, he adds, Occupying different positions in the ESC over the LV function parameters in patients with hypertension, centres themselves need to be accredited so patients can be last 15 years (including founder and first President of and demonstrating the value of new biomarkers for risk reassured by standards of equipment and medical trainees the European Association of Echocardiography, and stratification in acute MI, heart failure and pulmonary have full confidence in the training they are offered. chairperson of the 2009 and 2010 Congress Programme hypertension. ‘I’m fortunate to have wonderful people Development and implementation of the ESC’s Committees) has given Professor Pinto unique insights working with me, both at the ESC and in my department, integrated eLearning platform will take priority. ‘This into the workings of the Society. ‘To serve the ESC offers who will help me to achieve these goals. Good organisation is a very powerful tool with multiple potential uses at an opportunity to work closely with your peers for the and networks of communication are essential.’ different levels, with an endless capacity to include good of communities - fighting CVD and the promotion With five children, ranging in age from 26 to six years, different contents and with potential use by the different of healthy lifestyles is the major contributor to improved his home life requires comparable levels of organisation.

SATELLITE SYMPOSIUM Cairo – Village 4 / September 2nd (Tue), 12:45 – 13:45 Cardio-Ankle Vascular Index – CAVI Establishment of a New Global Arterial Stiffness Index

CHAIRMAN CO-CHAIR Prof. Roland Asmar Prof. Magnus Bäck Foundation-Medical Research Institutes Karolinska University Hospital, Sweden Switzerland & Hôpital Hôtel Dieu, France

Speakers Prof. Kohji Shirai Prof. Athanase Benetos Toho University, Sakura Medical Center, Japan University Hospital of Nancy, France “Principles of the Cardio-Ankle Vascular Index “Role of Metabolic Factors on Vascular Aging: and its Clinical Utilities.” The European Multicenter Triple A Study.” Prof. Bryan Williams Prof. Giuseppe Schillaci University College London, UK University of Perugia,Italy “Needs to Evaluate Arterial Stiffness and “Arterial Stiffness & the Heart – a Cross-talk” Central BP ”

Cardio- A nkle Vascular Index

www.escardio.org #ESCcongress 6 Pre-treatment with P2Y12 inhibitors in ACS? Continuing debate on the use of antiplatelet drugs says Stefan James YES, Consultant Cardiologist, Uppsala University Hospitals, Sweden

A C U T E randomised groups. Cangrelor, a potent, monotherapy has been shown consistently patients referred for primary PCI had acute coronary very fast acting iv P2Y12 receptor inhibitor in Horizons-AMI, EUROMAX and CABG after cath. In patients with NSTEMI syndromes are was shown to reduce peri- and early post- recently in HEAT-PPCI to be associated there is no need for urgent CABG. often caused by procedural events in the Phoenix trial with high early risk of stent thrombosis In conclusion, as supported by guidelines, intracoronary compared to clopidogrel. These data together without sufficient potent platelet inhibition. patients with STEMI and NSTEMI should thrombus suggest that potent platelet inhibition at the A potential drawback with early pre- routinely receive aspirin at first medical formation time of PCI is important to avoid peri- and treatment with potent P2Y12 receptor contact and pre-treated with P2Y12 with blockage early post-procedural events. inhibitors is increased bleeding risk in inhibitors as early as possible and before of antegrade The Atlantic trial is currently testing the association with acute need for CABG. PCI. For STEMI in the pre-hospital setting coronary flow effect on ST segment resolution and TIMI However, the PLATO trial showed that with limited diagnostic possibilities here leading to myocardial ischaemia and cell flow of ticagrelor administered in the pre- ticagrelor was particularly beneficial in there is a greater risk of misdiagnosis. death. Thrombus burden, reduced coronary hospital setting as compared to prior to PCI. patients who underwent CABG in the trial. Treatment with potent P2Y12 inhibitors flow and reduced myocardial perfusion Unfortunately, the trial is not designed to Ticagrelor may be discontinued two days should therefore be only after appropriate are important negative predictors of poor evaluate the effect of peri-procedural and prior to CABG as per the PLATO protocol. evaluation of the patients’ status, history clinical outcome, including recurrence of early post-procedural thrombotic events, Furthermore, acute CABG is no longer a and ECG by a physician. Only if the myocardial infarction, stent thrombosis and which is the main reason for early initiation clinically reasonable alternative in patients ATLANTIC trial shows harm should this death. Prompt initiation of antithrombotic of potent platelet inhibition. Bivalirudin as with STEMI. In Sweden only 0.02% of all strategy be changed. therapy in combination with PCI is the preferred approach to optimise myocardial says Gilles Montalescot perfusion and outcomes in most patients Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris with ACS. NO, Inhibition of platelet activation via the P2Y12 platelet receptor is a cornerstone of treatment during and after PCI for ACS for THE IDEA there was a three-fold increase in all major • similar hazard with clopidogrel for an reduction of peri- and early post procedural behind pre- bleeding not related to coronary bypass uncertain benefit with an invasive strategy thrombotic complications. Randomised treatment in grafting (CABG) and six-fold increase in • no data with ticagrelor: absence of proof trials and a meta-analyses including more non-STEMI life-threatening bleeding not related to is not proof of absence of a problem! In the than 18,000 patients across the spectrum is that oral CABG. The harm was associated with PLATO study all patients were pre-treated of ACS have shown that pre-treatment with P 2 Y 1 2 no benefit on the ischaemic side and no and all patients in both groups may have clopidogrel significantly reduces ischaemic antagonists subgroup appeared to have a favourable been similarly harmed by pre-treatment complications after PCI compared with need some risk/benefit ratio from pre-treatment. The Before the coronary angiogram and starting treatment at the time of PCI without time to large cohort of patients undergoing PCI unlike STEMI, NSTE-ACS patients increasing major bleeding risk. reach full performed as well with prasugrel loading have a limited likelihood of having both Potent P2Y12 receptor inhibition with activity and on the table as those who had been pre- an accurate diagnosis and a treatment prasugrel starting at the time of PCI is that the drugs are needed during the period treated by prasugrel. Pre-treatment did not requiring a stent. According to both superior to clopidogrel for patients with of medical treatment. This view derives from prevent better peri-procedural MI but was randomised studies and registries, up to ACS. However, the ACCOAST trial showed the CURE study when indeed clopidogrel associated with a large excess of bleeding 15% of patients with NSTE-ACS do not have that a strategy of a half dose of prasugrel 4 had a slow onset of action and was used in complications. Routine pre-treatment confirmation of CAD after the angiogram, hours before PCI and an additional half dose patients managed conservatively (80% of strategies in NSTE-ACS are not valuable up to 10% require CABG surgery within at the time of PCI was not superior to a full the CURE patients had no PCI performed). options in the modern era of rapid (<48 the same hospitalisation, and up to 25% loading dose at the time of PCI in patients However, this is not so with the new P2Y12 hours) access to the cath lab with fast-acting of patients are treated medically without with non-STEMI but associated with a antagonists, which have a rapid onset of drugs available. revascularisation after the angiogram. All higher risk of major bleeding. action and are used in patients managed Moreover, there is converging evidence these patients are overtreated by being Ticagrelor, a reversibly binding potent invasively within 48 hours of admission against systematic pre-treatment in NSTE- pre-treated before the angiogram. Better P2Y12 receptor inhibitor, was superior - as like in ACCOAST when 99% had ACS patients: to have a quick look first at the coronaries to clopidogrel without increasing major catheterisation performed. In this study • similar findings in two large randomised rather than leap for a hazardous prescription bleeding events in the PLATO trial that prasugrel was effective within one hour of studies testing pre-treatment with of P2Y12 antagonists in NSTE-ACS by design included pre-treatment in both administration. In the pre-treatment group, glycoprotein IIb/IIIa inhibitors patients. Upturn in coronary events in wake of hurricane Sandy THE LINK BETWEEN natural disasters Hurricane Sandy struck the weeks to 335 events, 62 more than and an upturn in cardiovascular events Northeastern USA in October 2012 expected (p<0.0001). is now beyond doubt. Hurricane Katrina and in its wake left a trail of misery and In addition, the total number of AMI prompted a three-fold increase in AMI destruction whose cost has been put at deaths (in-hospital plus out-of-hospital) admissions, and significantly higher more than $68 billion. increased by 28%, from the expected rates of psychiatric co-morbidities. A study of in-hospital and out-of- 120 to 154 deaths per 100,000 person- Even the man-made disaster of the hospital deaths in New Jersey has now weeks, 34 more events (p<0.0001). The Greek financial crisis saw an increase compared the effect of Hurricane Sandy investigators reported that there was no in hospital admissions in Greece for on the incidence and mortality rates of rebound decrease in these effects in the both atrial fibrillation and heart attack AMI in high and low impact counties two weeks immediately after Sandy and following the banking onslaught of of New Jersey. Comparisons were made the effects in low impact counties were 2008. between the two Hurricane Sandy weeks not statistically significant. Now, a study from the Rutgers of 2012 and the same two weeks in the Studies suggest that CVD mortality Medical School in New Jersey, reported five previous years and the two weeks shows a seasonal trend that can be in an Abstract Session yesterday, preceding and following the hurricane. associated with cold weather, and this shows that Hurricane Sandy, the largest In the high impact counties there was study, the authors say, provides further Atlantic hurricane on record, was also a 23% increase in the number of AMI evidence of the impact of extreme associated with a steep increase in the events during Hurricane Sandy, from an weather conditions on the rates of acute incidence of coronary events. expected 273 events per 100,000 person- coronary events.

www.escardio.org #ESCcongress 7 Heart failure with preserved ejection fraction still a major clinical challenge IN THE 21ST CENTURY it seems truly ESC guidelines recommend thresholds astonishing that no evidence-based of 50%, while CHARM Preserved used therapies exist to treat heart failure with less than 40% and I-PRESERVE less than preserved ejection fraction (HFpEF). ‘With 45%. ‘The concern therefore remains that such lack of effective treatments, HFpEF patients recruited in neutral trials didn’t is undoubtedly one of the largest unmet have HFpEF but LV hypertrophy with needs in cardiovascular medicine,’ said non-cardiac reasons for dyspnoea such as Carolyn Lam, speaking after a Symposium obesity,’ he said. yesterday on the challenges in HFpEF. Furthermore, published trials show In stark contrast to heart failure with heterogeneity in patient profiles, such as reduced ejection fraction (HFrEF), survival differences in plasma BNP. Geographic statistics for HFpEF have not changed variations also play a role, with the over the past two decades. ‘Fundamental TOPCAT study (spironolactone in HFpEF problems exist in our understanding of Carolyn Lam: ‘Survival statistics have not Carsten Tschoepe: ‘Controversy in the cut-off patients) showing striking differences HFpEF - even how to recognise and manage changed over the past two decades.’ between preserved and normal EF.’ in outcome for patients from the US and it,’ said Lam from the National University said Lam, support the concept of distinct ‘preserved’ or ‘normal’ EF. Eastern Europe. ‘We need to homogenise Heart Centre, Singapore. Prevalence is disease entities. Left ventricular chamber Current international guidelines, said criteria for inclusion in future HFpEF expected to rise, with estimates suggesting dilation (eccentric remodelling) is a specific Scott Solomon, from Harvard Medical trials,’ said Komajda. that by 2020 HFpEF will account for two- characteristic of HFrEF, whereas in HFpEF School, acknowledge the lack of evidence The way forward, suggested Lam, is to thirds of hospitalised HF patients. chamber size is near normal with increased for therapies in the management of shift the focus to a new paradigm of HFpEF ‘We have perpetuated the idea that HF wall thickness relative to chamber HFpEF. Guidelines, he added, recommend emphasizing endothelial dysfunction is synonymous with pump failure, and dimensions (concentric remodelling). treatments for symptoms, such as diuretics and the role of a pro-inflammatory state restricted clinical trials to patients with Diagnosis is hampered by the fact to relieve breathlessness and oedema, leading to reduced nitric oxide EFs less than 35-45%. This has excluded no biomarkers have been identified to management of hypertension, and control bioavailability in cardiomyocytes and patients with HFpEF by design,’ said Lam. provide objective tests for HFpEF. ‘BNP of heart rate (elevated heart rate is usually reduced myocardial cyclic guanosin 3’,5’– One of the difficulties has been the lack is a marker of wall stress, and wall stress poorly tolerated in patients with stiff left monophosphate (cGMP) content. of requirement for hospital registries to doesn’t play such a significant role in ventricles). Currently the SOCRATES study measure EFs, with the result that breakdown HFpEF,’ explained Carsten Tschoepe Michel Komajda, from the Pitié is exploring whether a stimulator of of HF according to EF is largely unknown from the Charité Hospital, Berlin. Hence Salpetrière Hospital, Paris, reviewed recent guanylate cyclase (a key enzyme in the in some parts of the world. diagnosis needs to be made according to trials performed with ACE inhibitors and cGMP signalling pathway) might be One hotly debated issue is whether three features: clinical signs and symptoms ARBs - including PEP-CHF, CHARM effective; while the PARAGON study HFpEF represents a transitory stage to of HF, evidence of preserved EF, and Preserved, and I-PRESERVE, all of which will investigate whether inhibitors of HFrEF or a distinct entity in its own right. evidence of abnormal LV structure and or proved negative. One challenge for such neprilysin (which increase intracellular Differences in patterns of LV remodelling diastolic dysfunction. An area of continued trials, he explained, is that no consensus cGMP) might be beneficial. at the chamber and ultra-structural levels, controversy is the optimal cut-off to define exists for the definition of normal EF.

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www.escardio.org #ESCcongress What is the biggest unmet need in cardiology?

For us, the newest treatments for cardiac diseases One of the biggest problems at medical school was are available but their cost effectiveness cannot be getting enough exposure to procedures to encourage “translated to the whole population. In India, this “entry into cardiology. It’s really hit and miss. While results in a two-tier system - there are a lot of people there was plenty of theoretical book work, there who are uninsured so they don’t have the resources weren’t nearly enough opportunities for exposure to pay for these new treatments. And as doctors it to practical cardiology procedures. We saw some means we’re limited in giving the best treatment, angioplasty, but few other procedures. In anatomy such as CRT devices and new-style stents to patients. we never even saw a real heart. We were lucky to So what we’re trying to do is educate people into work for an inspiring intensive care consultant - he coming to hospital as early as possible. Prevention is even suggested we should come to the ESC. But also key, even though hospitals can subsidise the cost the difficulty for medical students is getting enough by bulk-buying drugs and devices. exposure to cardiology to make them want to take up the discipline in the first place. The lack of Ashok Jain ” Stefano Cornara experience also makes it difficult for us to decide Interventional cardiologist Newly qualified doctor what type of cardiologist we’d like to be. India waiting for residency Pavia , Italy ” faces in the crowd When it comes to primary prevention in cardiology In my opinion, it’s how we deal with acute MI. In facesthere’s still a huge unmet need.in Nowadays so much the crowdmany countries the time delay to treatment is more can be done to try and reduce the risk of getting “than specified to prevent heart damage. There are “heart disease in the first place. In my practice I’m huge issues and I’m working to educate physicians using ultrasound of the carotid arteries to determine in emergency areas in how they can detect an acute whether patients have any evidence of atherosclerosis. MI immediately. The time delay in Mexico at the If this is found to be the case I prescribe vigorous moment is about 300 minutes and there are many prophylactic treatment. The reality is that it doesn’t factors to blame for this, such as transport (to matter if patients have high cholesterol levels if they hospital) and recognising the signs such as chest show no signs of atherosclerosis inside their arteries. pain. What’s needed is more awareness about the When you can show patients the concrete evidence of symptoms, otherwise people end up suffering more such plaques it really motivates them to try to reduce damage - and increased costs for the health system. risks. I’d like to see more cardiologists making such Arnfinn Bakke Nanbjor screening tests routine. Ursulo Juarez-Herrera ” Cardiologist in practice Cardiologist at the National Institute Hamar, Norway ” of Cardiology Mexico City, Mexico

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Satellite Symposium

Triple combination therapy in hypertension:

Beirut Room - Village 6 fulfilling new expectations Tuesday, September 2, 2014 (12.45-13.45) Chairpersons Antonio Coca Giuseppe Mancia Faculty Organized by John Chalmers, Alistair Hall