What news did the 2013 European Congress of Cardiology in Amsterdam bring? Discussed were not only practice-relevant guidelines, but also the current trends regarding lifestyle modifications. Furthermore, studies on the treatment of coronary artery disease and heart failure were presented and the improved safety profile of the new oral anticoagulants was emphasized.
During the European Congress of Cardiology (ESC) in Amsterdam at the end of August 2013, four practice-relevant guidelines were presented and extensively discussed:
- Stable coronary artery disease: the new version emphasizes imaging techniques such as cardio-MR and cardio-CT. They are intended to help select patients for the right investigation, primarily with the goal of not overusing methods. In particular, we are concerned with the adequate use of cardio-CT with a good negative predictive value at lower pretest probability. Diagnostic algorithms are based on pretest probability related to clinic and risk profile.
- Diabetes, prediabetes and cardiovascular disease: For the population of Europe and North America, experts estimate a 30-40% probability of developing type 2 diabetes mellitus once in a lifetime. All patients with diabetes and an additional risk factor or signs of target organ damage or microalbuminuria are classified into the “very high risk” group with a corresponding target LDL cholesterol value ≤1.8 mmol/l. All other diabetes patients belong to the “high risk” category. Glucose control should be individualized, taking into account duration of diabetes, age, and comorbidity. As a rule, a target HbA1c value of <7.0% applies. In selected patients with a short duration of disease, long life expectancy, and lack of significant cardiovascular disease, aim for an HbA1c of 6.0-6.5%. In elderly patients with long-standing and/or complicated disease, an HbA1c of 7.5-8.0% is the goal.
- Pacemaker and CRT Guidelines: Guidelines includes a large chapter with a concrete “how-to-approach” for practitioners. Bradyarrhythmias have been reclassified according to the mechanism of the disease rather than the etiology.
- Arterial hypertension: these are guidelines adopted jointly with the European Hypertension Society with an update on the selection of individual antihypertensives. Treating physicians are urged to use antihypertensives more proactively and to make their patients even more aware of the dangers of long-standing untreated high blood pressure.
Lifestyle trends are going in the wrong direction
On the occasion of the congress the results of EUROASPIRE IV have been presented. This shows that the implementation of the drug and non-drug recommendations of the ESC guidelines for secondary cardiovascular prevention is not yet optimal. Compared with surveys in 1999/2000 and 2006/2007, the current survey of 2012/2013 in patients with established coronary artery disease shows that risk factor control remains inadequate or has even worsened in some cases.
Smoking despite CHD: About half of the study participants were able to stop tobacco use after a cardiovascular index event (acute coronary syndrome with percutaneous coronary intervention or bypass surgery). However, there are large differences between different countries: while 71% of the French continue to smoke despite established coronary heart disease, only one in four Spanish CHD patients does so.
The highest rate of smoking affects the age cohort under 50, the cohort that would potentially benefit the most in the long run from nicotine cessation.
Increasing overweight: The prevalence of overweight increased significantly over the three survey periods from 50% to 57%. Physical activity did not increase over the observation period. The prevalence of diabetes increased from 18 to 27% (P=0.0004!).
Treated but not on target: the proportion of patients on statin therapy has risen to almost 90%. However, even in the last survey, only just under 60% achieved the LDL cholesterol target of <2.5 mmol/l according to European guidelines in 2007. The situation is no different when it comes to treating blood pressure. Thus, the overall gap between targets and outcomes achieved in registries in secondary prevention has not narrowed over the past 15 years. This makes efforts in the area of lifestyle modification, measures in the area of cardiac rehabilitation, and raising awareness among all specialists working in the field of primary and secondary prevention all the more important.
Coronary heart disease
In the future, copeptin, a biomarker for cardiac stress, may help in the diagnosis of acute coronary syndrome (AKS) to exclude AKS even earlier in the case of negative high-sensitivity troponin. The BIC-8 study shows that with a copeptin level of <10 pmol/l and a low hs-troponin level, patients can be safely discharged without risk of developing AKS.
Pretreatment with prasugrel before PCI in NSTEMI patients is questioned by the results of the ACCOAST trial. In this study, more than 4000 patients with NSTEMI have been randomized to an aspirin and 30 mg prasugrel group versus an aspirin and placebo group in AKS between 2 and 48 hours before angiography. The pretreatment group received an additional 30 mg of prasugrel at the time of PCI, and the control group received 60 mg immediately before the intervention. The study was stopped early because of increased bleeding risk in the prasugrel early treatment group. Within 1 month of NSTEMI onset, there were no significant differences in both groups with respect to cardiovascular death, myocardial infarction, stroke, and emergency revascularization. The study once again indicates that uncritical administration of dual antiplatelet therapy in NSTEMI may increase the risk of bleeding in a certain group. It will be interesting to see how the revision of the NSTEMI guidelines, which have been in effect since 2012, will take this new study into account.
One study that challenges the current valid STEMI guidelines is the so-called PRAMI study. Currently, in ST elevation infarcts, only the so-called culprit lesion, i.e., the site judged to be responsible for the AKS, should be dilated and stented, and additional sites should be addressed simultaneously only in patients with refractory angina. In this multicenter study from England, 465 patients with STEMI and multivessel disease were randomized to a group with culprit lesion PCI only and to a group with concurrent PCI also on the stenosed noninfarct vessels. Important: Patients in cardiogenic shock, with previous bypass surgery, significant main stem stenosis, or patients with chronically occluded vessels were excluded. The PRAMI trial demonstrated that even in the absence of evidence of ischemia, a significant stenosis in a large vessel that was not responsible for the current myocardial infarction should be dilated.
In out-of-hospital resuscitation, the multicenter LINC study from six countries shows no benefit of systematic mechanical compression over manual compression in terms of survival and neurological outcome of resuscitated patients. More crucial is rapid defibrillation.
Coronary revascularization: PCI vs. CABIG
The 5-year results of the SYNTAX trial published in 2013 showed that in complex disease with a high or intermediate SYNTAX score, which is based on angiographic findings, patients receiving cardiac surgery experienced fewer cardiac or cerebrovascular events. Repeat revascularizations were more frequent after PCI (26 vs 13.7%). However, the drug-eluting stents used today suggest improved performance compared with the first-generation (TAXUS) stent used in the SYNTAX trial. Thus, the SYNTAX study will become anachronistic the longer it lasts.
News on oral anticoagulation
In addition to dabigatran, the only thrombin inhibitor, and the two factor Xa antagonists rivaroxaban and apixaban, edoxaban, a third factor Xa inhibitor, is on the horizon. The HOKUSAI study presented at the ESC Congress and published simultaneously in the New England Journal shows that edoxaban is equal to warfarin in efficacy and superior in safety in venous thromboembolism. In this study of more than 8000 patients, edoxaban was compared with warfarin in patients with deep vein thrombosis or pulmonary embolism after an initial five- to ten-day treatment with low-molecular-weight or unfractionated heparin. Edoxaban was particularly better than warfarin in the severe pulmonary embolism subgroup, with a 50% reduction in event rate. At the same time, the risk of relevant and nonrelevant bleeding was significantly reduced with the use of edoxaban.
Dabigatran in patients with mechanical heart valves disappointing: Dabigatran is not effective in preventing thromboembolic events in mechanical heart valves according to the RE-ALIGN trial. This study investigated whether the prevention of valvular thrombosis or thromboembolic events in mechanical heart valves could be performed with dabigatran instead of vitamin K-dependent oral anticoagulants. The study has been stopped early because of an increased rate of embolism, myocardial infarction, or death in the dabigatran group. At the same time, more bleeding has also occurred. Thus, for the time being, Marcoumar or Sintrom remain the drugs of choice in patients with mechanical valve prostheses.
In summary, the trials of the new oral anticoagulants in nonvalvular atrial fibrillation that have been presented or published in the past year consistently show an improved safety efficacy profile. However, it is important to keep certain precautions in mind: kidney function and concomitant medication must be checked regularly. A small group of patients should still receive traditional oral anticoagulants: Patients with valvular atrial fibrillation (mitral stenosis), patients with mechanical heart valves, and patients with severe renal and hepatic dysfunction.
Heart failure – valve diseases
A paper shown at the ESC finds that more than 90% of patients with chronic heart failure with impaired pump function and persistent dyspnea NYHA II-IV receive an ACE inhibitor or angiotensin receptor blocker and beta blocker. A mineralocorticoid receptor antagonist is also administered in about two-thirds of patients. However, the recommended target dose is reached at most at 20-30% percent.
In the treatment of diastolic heart failure, promising approaches exist such as treatment with the mineralocorticoid receptor antagonist spironolactone or with the angiotensin receptor neprilysin inhibitor LCZ 696. However, no clinically relevant improvement in efficacy over standard therapy has been demonstrated to date. The main focus is still on the treatment of the underlying arterial hypertension of a possibly accompanying myocardial ischemia and, if necessary, frequency control in atrial fibrillation.
The echo-CRT trial has shown that biventricular “pacing” is not indicated in heart failure with NYHA III-IV dyspnea and a left ventricular ejection fraction below 35% with a narrow QRS complex (<130 msec), even if mechanical dyssynchrony can be detected on echocardiography. In this study, there was an increased cardiovascular event rate (death and hospitalization) in the CRT-treated collective.
In summary, the conventional ECG remains the best tool for indication: left bundle branch block and/or a QRS width of >150 msec is a clear indication for resynchronization in heart failure and a left ventricular ejection fraction below 35% with reduction of mortality. With a QRS width between 120 to 150 msec without left bundle branch block, the situation is still unclear, and new studies are needed. If the QRS width is less than 120 msec, resynchronization is contraindicated.
The number of percutaneously implanted aortic valves is also increasing rapidly in Switzerland. In a large meta-analysis, the most common complications were AV block, vascular complications, and renal failure. The 1-year survival rate from the total of over 16 000 patients included is 79.2%.
Literature by the author
CARDIOVASC 2014; 13(1): 4-6
