XXIV ESC Congress

In September, Cardiovascular News attended the XXIV European Society of Cardiology (ESC) congress, the largest meeting of cardiologists in Europe, which took place in Berlin. There were around 20,000 attendees at the congress this year.

At the congress the latest data from the Euro Heart Survey programme, which aims to provide systematic information on patient management in Europe, were released. Presenting the latest results from the Euro Heart Survey Maarten Simoons, ESC President, said that data in the report ‘Cardiovascular Diseases in Europe’ showed marked differences in the mortality from CVD among European countries and that many patients were not receiving optimal medical therapy. Simoons went on: “The data show that care for the patients is more driven by the facilities of the hospital than the needs of the patient; where as it should be the needs of the patient that drive treatment.”

The Euro Heart Survey programme is designed to describe patient presentations, management and outcomes of cardiovascular disease in European medical centres. Surveys presented at the congress included Coronary Revascularisation and Valvular Heart Disease.

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Coronary Revascularisation
This survey was aimed at monitoring the invasive procedures performed throughout Europe in catheterisation laboratories, as well as the treatment decisions based on the results of diagnostic angiography. The timing of the survey was critical since patient inclusion was stopped before the introduction of drug-eluting stents, which are likely to have a significant impact. This survey, conducted under the leadership of William Wijins, screened 8,478 patients in 119 centres located in 29 member countries of the ESC. Each centre was supposed to provide data on 40 consecutive patients. The final number of 6,302 recruited patients included those with stable angina (54%), non-ST elevation acute coronary syndromes (30%), ST-elevation acute myocardial infarction (16%). After coronary angiography, about 60% of patients underwent percutaneous interventions, while the other 40% were almost equally divided between surgery and medical treatments. Of the percutaneous interventions, 94% resulted in technical success. No stenting was attempted in 28% of patients, in 26% direct stenting was used, and in 46% conditional stenting was applied. In-hospital outcome showed mortality of about 1.4%, non-fatal myocardial infarction at around 3% and a low rate of crossover to surgery (about 0.2%). Dr Wijns also provided the preliminary information on the adherence to the guidelines.

Valvular Heart Disease
This survey was designed to define the characteristics, treatment and outcomes of patients with valvular heart disease treated in different European countries, and to examine the adherence to current practice guidelines. 5,001 patients were included in this survey, which is the largest worldwide population study in this field. Professor Alec Vahanian, chairman of the Euro Heart Survey on Valvular Heart Disease, presented the main findings of this survey:

70% of patients had native valve disease, but as much as 30% of them had had previous interventions.

Aortic stenosis was the most frequent native valve disease followed by mitral regurgitation.

Degenerative aetiology is by far the most frequent, but endocarditis is still a serious concern.

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Hotline session highlights
The hotline sessions at ESC 2002 saw the presentation of clinical results relevant for clinical practice:

Hot Line Session I – Acute coronary syndromes
In the session Hot Line I, data gave the clear message that intervention is better than conservative treatment:

The RITA 3 study, sponsored by the British Heart Foundation, demonstrated that interventional strategies are preferable to conservative treatment for patients with non-ST segment elevation (unstable angina). In the study, 1,810 patients were randomised in 45 study sites in the UK and the treatment strategies were well separated (96% coronary angiography in the intervention arm versus 16% conservative arm by hospital discharge and revascularisation rates at one year were 57% versus 27% respectively). Median follow up was two years. Deaths or myocardial infarctions were similar in both treatment groups at one year (7.6% intervention versus 8.2% conservative) and longer-term follow-up is in progress to assess the impact of intervention on prognosis. Highly significantly improvements occurred in the frequency of angina and the use of anti-anginal medications with the interventional strategy.

Data from GRACIA, the Spanish equivalent to acute ischaemic heart disease study group (Grupo de Análisis de la Cardiopatia Isquémica Aguda) presented by Francisco Fernandez-Aviles, indicated that it is safe to perform cardiac revascularisation procedures within 24 hours of thrombolytic treatment and that they reduce hospital stays and the possibility of further heart problems after discharge. The study enrolled 500 patients, who were assigned to two different strategies: the post-thrombolysis classical drug-based treatment or an early interventional strategy consisting of performing cardiac catheterisation within 24 hours of thrombolysis followed by the reparation of coronary arteries by means of the implantation of a stent. The mortality after 30 days was similar in both groups; the hospital stay was nearly half in the interventional group.

The PRAGUE 2 study (Primary Angioplasty in AMI patients from General community hospitals transported to PTCA Units versus Emergency thrombolysis) showed that the transport of patients < 12 hours after the of symptoms of acute myocardial infarction from a general community hospital to interventional treatment is superior to immediate thrombolysis within the primary teaching hospital.

Hot Line II – Coronary artery disease and rhythm disorders
The aim of the German randomised multicentre ACE (Anticoagulation for Cardioversion using Enoxaparin) study showed that enoxaparin, the new, low molecular weight heparin, is at least as safe and effective as conventional treatment with heparin when used to prevent thrombo embolisms in cardioversion treatment for atrial fibrillation. The study included 496 patients that were randomised to receive either enoxaparin subcutaneously or intravenous heparin, followed by phenprocoumon. Of the 496 randomised patients, 68 were excluded because of protocol deviations. Of the remaining 428 patients (216 enoxaparin : 212 heparin/phenprocoumon), embolism, major bleeds or death were reduced to 3.2% in the enoxaparin group compared to 5.7% in the conventional group. Therefore enoxaparin is at least as effective and safe as the conventional approach in the cardioversion for AF.

Results from the OPTIMAAL (Optimal trial in Myocardial Infarction with Angiotensin II Antagonist Losartan) study showed no difference in mortality between the complicated ACE inhibitor captopril and the angiotensin II antagonist losartan in patients with acute MI. The study, initiated at the University of Oslo, enrolled 5,477 patients with acute MI complicated by factors placing them at high risk from developing heart failure. A total of 329 study centres in seven European countries participated. Patients were randomised to treatment with captopril (150mg daily) or losartan (50mg daily). A total of 946 deaths, 763 reinfarctions, 272 strokes and 9,183 all cause hospitalisations occurred during the average 2.7 years of follow-up of the trial. The baseline characteristics of the patients in both treatment groups in the study were comparable and only one patient was lost to follow up. Approximately 80% of the patients were still on blinded therapy at the end of the study.

BEST (Balloon Equivalent to StenT) showed that the use of intravascular ultrasound (IVUS) imaging made it possible to improve the balloon angioplasty procedure, using a stent in just 45% of cases, producing similar clinical and angiographic results to those obtained with systematic stent implantation. This study was partly funded by the French Ministry of Health and partly by a grant from Boston Scientific. Three French centres included a total of 254 patients suffering from narrowing of the coronary arteries and who were treated either by systematic stent implantation or by IVUS-guided angioplasty. Among the patients treated by IVUS-guided angioplasty, stents were used in 45% of cases to optimise the result.

Preliminary results of the Euro-SPAH (EUROpean Sonotherapy Prevention of Arterial Hyperplasia) study were presented by Patrick Serruys. Between October 2000 and January 2002, 403 patients were recruited from 23 hospitals across Europe. There was no different between the sonotherapy and ‘sham’ groups’ re-growth of tissue within the stents. MACE rate was similar in both groups.

The results of the PRAGUE 4 study, presented by Petr Widimsky, showed that in this single centre study of consecutive patients assigned to bypass surgery the use of the off-pump technique gives comparable surgical and outcome results. The conclusions were:

Beating heart (off-pump) coronary bypass surgery is applicable in 84% of consecutive surgical patients.

It reduces costs.

It is at least as clinically effective and safe as classical ‘on pump’ surgery.

When analysed by ‘intention-to-treat’ both techniques have similar results.

However, patients in whom off-pump technique was used tend to have better outcome.

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EuroACTION
The congress saw the launch of EuroACTION, an initiative aimed at raising the standards of preventative cardiology across Europe, closing the gap between guidelines and practice, and improving the millions at risk, or already suffering from, coronary heart disease. The study will investigate whether improved drug therapy and professional support to help 20,000 CAD patients and their relatives from six countries to change their life-styles could help reduce morbidity and mortality. The EuroACTION programme will offer professional support to hospital CAD patients, their first-degree relatives and people from primary care considered at high risk of developing CAD.

Professor David Wood, the study’s principal investigator said: “This programme is a major professional initiative by our society to change the way physicians and other health professionals manage coronary heart disease. Many suffers and those at risk from coronary heart disease are not taking the steps they need to protect themselves against the world’s number one cause of death. By using a multi-disciplinary team of health care professionals we can help patients and their relatives achieve their lifestyle and
risk factor goals. Improving measure will improve both the quality of life and life expectancy.”

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