Editor's Corner: Rome in August | Alfred A. Bove, MD, PhD, Editor-in-Chief, CardioSource WorldNews
CardioSource WorldNews | Some events can be ascribed to luck or to coincidence, and those terms might be the best way to describe the logistics of the annual meeting of the ESC in Rome this past August. It was quickly evident that transportation to the new convention center near the Fiumicino airport would be challenging, and many attendees spent inordinate amounts of time travelling between downtown hotels and the convention center to find themselves in airport style security lines before entering the building. While security was a burden, given the state of world affairs, we were reassured by the participation of the Italian security system in guarding the convention.
This year’s meeting offered a wide variety of topics useful to the practicing cardiologist, but I wouldn’t single out any one as a block buster that resulted in significant changes in clinical practice. We heard more about implanted devices that help improve cardiac function. They continue to have limited application to patients with end stage heart failure, but may be useful in a carefully selected group of heart failure patients. The study ENSURE AF comparing Warfarin to therapy with edoxaban showed that stroke and bleeding events post cardioversion were lower with edoxaban compared to warfarin, and this carried over to use of transthoracic echo only for evaluating AF outcome. There is a growing acceptance of the NOACs for cardioversion and we should see more detailed guidance on how to use them for cardioversion in future studies.
The SAVE study looked at the value of treating sleep apnea for reducing cardiovascular event in patients with existing cardiovascular disease. Sleep apnea subjects were found using a novel home screening tool that doesn’t require a sleep study laboratory to diagnose the disorder. Their data did not show an improvement in cardiovascular events with use of C-PAP therapy although there was a suggestion that stroke rate may be reduced.
There is a growing trend to recommend exercise in patients with any cardiac disorder. The data support a clear morbidity and mortality benefit for patients with different forms of cardiovascular disease. Daily exercise is also useful for maintaining normal blood pressure in patients with hypertension. For these patients, exercise should be aerobic or dynamic, but isometric exercise does not appear to improve blood pressure control. The continuing problem with exercise therapy is the low adherence rate among patients recommended for exercise therapy, and continuing reluctance by insurers to cover the cost of exercise therapy.
The LEADERS-FREE sub study examined high bleeding risk patients over age 75, mean age 81, with AF, cancer, anemia or a prior bleed undergoing PCI with a polymer free stent or a BMS. The data showed a more favorable outcome after one month of dual antiplatelet therapy with the polymer free DES compared to a bare metal stent, but high bleeding risk persisted for 1 year in both groups. The several studies that examined outcome with bare metal vs the newer drug eluting stents and scaffolds suggest that shorter periods of DAPT can be used without excess stent thrombosis. Aggressive therapy for NSTEMI may not always be the correct choice. As we would expect, immediate invasive therapy for a patient with an unstable NSTEMI reduces early mortality, but in longer term follow-up even up to 15 years, mortality was the same with either conservative or early invasive therapy, but there may be a delay in new ACS events. Interest in bioabsorbable vascular scaffolds continues to grow. Inflammation on the polymer and training in deploying these scaffolds may influence their long term outcome. ABSORB Japan results showed no difference in MACE at 4 years. BASKET-SAVAGE examined DES vs BMS in saphenous vein grafts. Prior studies showed a higher long term risk of DES in bypass grafts. This study showed a substantial reduction in 36 month MACE in the patients who received DES versus BMS treatment, but 36 month mortality was unchanged, and there was no difference in stent thrombosis.
Interest in obesity effects on the heart continues. Previous studies examining the effects of obesity on the heart showed a significant reduction in AF when obese patients lost weight. Data from this meeting showed that left ventricular hypertrophy (LVH) can be reversed by weight reduction in obese patients.
Data from the IMPACT registry looked at risk factors for procedures in adolescents and adults with CHD. Older age, low arterial oxygen saturation, anemia, first procedure, and urgent vs elective surgery all contributed to poorer outcomes. Unprovoked DVT may not need lifetime anticoagulation if a low risk profile can be identified. In REVERSE II a clinical decision rule (HERD002) was able to identify women who are at low risk for recurrent DVT who can stop anticoagulation after 1 year.
The REM-HF study examined the value of frequent remote monitoring of heart failure patients with implanted defibrillators. There was no difference in mortality or unplanned admissions between the monitored and unmonitored groups. Self-care home measures that include BP, pulse rate, and activity all appear to be unaffected by frequent home monitoring. There seems to be no effect on clinical outcome of patients having their data. For all heart failure patients, 5%/year mortality is a consistent finding. Data from CLARIFY indicated that systolic BP < 120 and diastolic blood pressure < 70 was associated with increased cardiovascular events in patients with stable coronary disease. Optimal blood pressure is in the 120-140 systolic and 70-80 diastolic range.
This year’s meeting was a potpourri of trials that provided incremental changes in practice but no large trials that would result in significant changes in practice. Yet, many of the studies provided data that helps in patient care. And the food in Rome was superb.
Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
|Read the full October issue of CardioSource WorldNews at ACC.org/CSWN|
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