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Friday, May 10th 2019

08.15 – 09.30

Atrial Fibrillation

Chairpersons: Geneviève Derumeaux (Créteil, FR), Andrea Menafoglio (Bellinzona, CH), Lukas Kappenberger (Lausanne, CH)

08.15 – 08.30
Antiarrhythmic drugs for Atrial Fibrillation – State of the art

Gheorghe Dan (Bucharest, RO)

Description

Antiarrhythmic drugs for Atrial Fibrillation – State of the art

Gheorghe Dan (Bucharest, RO)


The 2016 the European guideline of atrial fibrillation (AF) management[1] indicates two main therapeutic and outcome endpoints in AF: actions designated to improve life expectancy and those intended to improve quality of life. If stroke prevention belongs to the first category, rate/rhythm control strategies, irrespective if pharmacological or interventional, belong to the second one. The same 2016 AF management guideline[1] offers several pharmacological options for drug conversion to sinus rhythm and its maintenance; however, these options are very limited for the majority of cases with structural heart disease such as heart failure (HF), ischemic heart disease (IHD) or significant myocardial hypertrophy. Amiodarone, with its multiple extra-cardiac side effects, remains the most efficient anti-arrhythmic drug. Although less efficient, other options for selected cases, are sotalol, dronedarone or vernakalant[2]. There is an important translational gap between currently available AADs and contemporary practical expectations. A new AAD paradigm should be based on clear understanding of the individual arrhythmic mechanism, evaluating its critical components and revealing the arrhythmia’s most vulnerable parameter as the target for the specific AAD. Moreover AF is increasingly considered as the consequence of a progressive atrial cardiomyopathy that also needs interruption (in addition to AF) in order to reach a higher therapeutic success rate[3]. An attractive target for rhythm control in AF is represented by some atrial-selective currents which show up-regulation during AF (arrhythmia-specific approach). Besides targeting a vulnerable parameter of arrhythmia determinants, drugs blocking these atrial-selective channels will be at least conceptually deprived of ventricular proarrhythmic effects. It is evident that we are lost in translation of basic research discoveries to the clinical practice, for which many obstacles exist [4][5]. The new paradigm moves our knowledge now from the “reductionism” concept of the “one drug one electrophysiologic target” to the more complex network interpretation of the patient with arrhythmias[6].

References

  1. P. Kirchhof, S. Benussi, D. Kotecha, A. Ahlsson, D. Atar, B. Casadei, M. Castella, H. C. Diener, H. Heidbuchel, J. Hendriks, G. Hindricks, A. S. Manolis, J. Oldgren, B. A. Popescu, U. Schotten, B. Van Putte, P. Vardas, S. Agewall, J. Camm, G. Baron Esquivias, W. Budts, S. Carerj, F. Casselman, A. Coca, R. De Caterina, S. Deftereos, D. Dobrev, J. M. Ferro, G. Filippatos, D. Fitzsimons, B. Gorenek, M. Guenoun, S. H. Hohnloser, P. Kolh, G. Y. H. Lip, A. Manolis, J. McMurray, P. Ponikowski, R. Rosenhek, F. Ruschitzka, I. Savelieva, S. Sharma, P. Suwalski, J. L. Tamargo, C. J. Taylor, I. C. Van Gelder, A. A. Voors, S. Windecker, J. L. Zamorano, and K. Zeppenfeld, “2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS,” Europace, vol. 18, no. 11, pp. 1609–1678, 2016.
  2. D. Dobrev and S. Nattel, “New antiarrhythmic drugs for treatment of atrial fibrillation.,” Lancet (London, England), vol. 375, no. 9721, pp. 1212–23, Apr. 2010.
  3. A. Goette, J. M. Kalman, L. Aguinaga, J. Akar, J. A. Cabrera, S. A. Chen, S. S. Chugh, D. Corradi, A. D’Avila, D. Dobrev, G. Fenelon, M. Gonzalez, S. N. Hatem, R. Helm, G. Hindricks, S. Y. Ho, B. Hoit, J. Jalife, Y.-H. Kim, G. Y. H. Lip, C.-S. Ma, G. M. Marcus, K. Murray, A. Nogami, P. Sanders, W. Uribe, D. R. Van Wagoner, S. Nattel, and Document Reviewers:, “EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication,” Europace, vol. 18, no. 10, pp. 1455–1490, Oct. 2016.
  4. D. Gal, B. Thijs, W. Glänzel, and K. R. Sipido, “A Changing Landscape in Cardiovascular Research Publication Output: Bridging the Translational Gap.,” J. Am. Coll. Cardiol., vol. 71, no. 14, pp. 1584–1589, Apr. 2018.
  5. J. Heijman, V. Algalarrondo, N. Voigt, J. Melka, X. H. T. Wehrens, D. Dobrev, and S. Nattel, “The value of basic research insights into atrial fibrillation mechanisms as a guide to therapeutic innovation: a critical analysis.,” Cardiovasc. Res., vol. 109, no. 4, pp. 467–79, Apr. 2016.
  6. G. A. Dan and D. Dobrev, “Antiarrhythmic drugs for atrial fibrillation: Imminent impulses are emerging,” IJC Hear. Vasc., vol. 21, pp. 11–15, 2018.
08.30 – 08.45
Advances in curative approaches

Maria Luce Caputo (Lugano, CH)

Description

Advances in curative approaches

Maria Luce Caputo (Lugano, CH)


Background
Catheter ablation of Atrial fibrillation is effective in restoring and maintaining sinus rhythm in patients with symptomatic paroxysmal, persistent, and probably long-standing persistent AF. Complete pulmonary vein isolation (PVI) on an atrial level is the best-documented target for catheter ablation, achievable by point-by-point radiofrequency ablation, linear lesions encircling the pulmonary veins, or cryoballoon ablation, with similar outcomes. PVI was initially tested in patients with paroxysmal AF, but appears to be non-inferior to more extensive ablation in persistent AF as well. The presentation will be focused on the most recent advances in atrial fibrillation ablation, including the comparison of the efficacy of PVI with radiofrequency versus cryoenergy (FIRE and ICE study) (1), the efficacy of PVI in patients with persistent atrial fibrillation and heart failure (CASTLE AF) (2) and the impact on the current clinical practice of the controversial results of the recent CABANA study (3).

Conclusion
The pulmonary veins isolation is an efficacious patients with atrial fibrillation. The improvement of technology is going to significantly ameliorate the acute and long term outcome of the procedure and to improve the effectiveness and the safety of the procedure. This therapy is becoming more and more a first line choice therapy for patients with atrial fibrillation.

References

  1. Kuck KH, Brugada J, Fürnkranz A, Metzner A, Ouyang F, Chun KR, Elvan A, Arentz T, Bestehorn K, Pocock SJ, Albenque JP, Tondo C; FIRE AND ICE Investigators. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2016 Jun 9;374(23):2235-45.
  2. Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, Merkely B, Pokushalov E, Sanders P, Proff J, Schunkert H, Christ H, Vogt J, Bänsch D; CASTLE-AF Investigators. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018 Feb 1;378(5):417-427.
  3. Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, Noseworthy PA, Rosenberg YD, Jeffries N, Mitchell LB, Flaker GC, Pokushalov E, Romanov A, Bunch TJ, Noelker G, Ardashev A, Revishvili A, Wilber DJ, Cappato R, Kuck KH, Hindricks G, Davies DW, Kowey PR, Naccarelli GV, Reiffel JA, Piccini JP, Silverstein AP, Al-Khalidi HR, Lee KL; CABANA Investigators. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Mar 15.
08.45 – 09.00
Neurocognitive function in atrial fibrillation: lessons from the Swiss atrial fibrillation cohort study

Stefan Osswald (Basel, CH)

Description

Neurocognitive function in atrial fibrillation: lessons from the Swiss atrial fibrillation cohort study

Stefan Osswald (Basel, CH)


AIM
Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions. SwissAF assessed the relationships between cognitive function and vascular brain lesions in the longterm.

METHODS
Patients with AF were enrolled in an observational cohort study at 14 centers in Switzerland. Brain MRI and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions (WMLs) were quantified by a central core laboratory. Silent brain lesions were defined as lesions on brain MRI in patients without a clinical history of stroke or transient ischemic attack.

RESULTS
The study included 1,737 patients (73±8 years, 28% women, 90% on oral anticoagulation). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7±3.3 in patients with and 25.8±2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9±3.1 vs. 25.8±2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (β = -0.26; 95% confidence interval: -0.40 to -0.13; p < 0.001).

CONCLUSIONS
Patients with AF have a high burden of infarcts and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognition, also among patients with clinically silent infarcts. Our findings raise the question of systematic MRI screening in patients with AF. (J Am Coll Cardiol 2019;73:989–99)

09.00 – 09.15
Stroke prevention: state of the art

Antoni Martinez-Rubio (Barcelona, ES)

09.15 – 09.30
Discussion

09.30 – 10.10

Chronic Heart Failure: A Paradigm Shift

Chairpersons: Georg Noll (Zurich, CH), Hector Ventura (Miami, US), Giogio Moschovitis (Lugano, CH), Paul Mohacsi (Zurich,CH), Sang Hong Baek (Seoul, KR)

09.30 – 09.45
A paradigm shift in the treatment of heart failure

Felipe Martinez (Cordoba, AR)

Description

A paradigm shift in the treatment of heart failure

Felipe Martinez (Cordoba, AR)


During the past three or four decades, the pharmacolgic management of heart failure was dominated by diuretics, beta blockers and mainly by ACEI (Angiotensine Converting Enzime Inhibitors). Only one drug, ivabradine, was incorporated to the guidelines with specific indication in patients with heart rate above 70 beats per minute. The old spironlactone and the new angiotensine receptor blockers (ARB),were lately prescribed as second line drugs. Surprisingly and optimistically, in the recent years, new drugs and new mechanisms in some of the ¨old¨compounds produced a real ¨new paradigm¨ in the treatment of chronic heart failure. The old group of aldosterone blockers became in the new group called MRA (Mineralcorticoid Receptor Antagonist), because the evidence of the crutial role of this receptor in proinflammatory and proliferative pathways conducting to cardiovascular dysfunction. After 20 years of the publication of RALES,(1) this group appears recomended in most of the guidelines as first line drugs. The discovery of a new dual inhibitor (LCZ696) containing valsartan and sacubritril ( neprilisine inhibitor) demmostrated in the PARADIGM trial (2) a significant superiority compared to enalapril in decreasing morbimortality in class II-IV heart failure patients. It was really the first time a new drug did beat the main gold standard in the treatment of that group of patients. And this was the trully start of a new paradigm in this therapeutic área. More recently, the SGLT2 i (Sodium GLucose Transporter 2 Inhibitors) or glifozines (3,4), a group marketed as ¨antidiabetic ¨, showed an unexpected lower incidence of hospitalization and death for heart failure, in diabetic patients compared with placebo. It produced a huge amount of new research with these compounds, in diabetic and non diabetic populations with and without heart failure. This enthusiastic scenario was reinforced by the publicatins of several potential new mechanisms of this group trough the inbition of the sodium hydrogen transpoter (5,6). In summary, in the next couple of years we will face results that will confirm or not in this new approaches are part of the provocative NEW PARADING IN THE TREATMENT OF HEART FAILURE

References

  1. Pitt B, Zannad F, Remme W, et al. The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure. N Engl J Med (1999); 341:709-717
  2. McMurray JJV, Packer M, Desai AS, et al. Angiotensin–neprilysin inhibition versus enalapril in heart failure. N Engl J Med. (2014);371(11):993-1004.
  3. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med (2015); 373(22):2117-28.
  4. Neal B, Perkovic V, Mahaffey K et al. Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med (2017); 377:644-657
  5. Sharma A, Cooper L, Fiuzat M et al. Antihyperglycemic Therapies to Treat Patients With Heart Failure and Diabetes Mellitus. J Am Coll Cardiol HF (2018) 6.10; 813-822
  6. orsal A., Wiggers H., McMurray J.J.V.(2018) Heart failure: epidemiology, pathophysiology, and management of heart failure in diabetes mellitus. Endocrinol Metab Clin North Am 47:117–135.
09.45 – 10.00
Management of Heart Failure: Achieving Synergy between Drugs, Devices and Intervention

Frank Ruschitzka (Zurich, CH)

10.00 – 10.10
Discussion

10.10 – 10.40

Coffee Break

10.40 – 11.15

Key Lecture – Acute Heart Failure

Chairpersons: Basil Lewis (Haifa, IL), Thomas Suter (Bern, CH), Felipe Martinez (Cordoba, AR), Marcello Di Valentino (Bellinzona, CH)

10.40 – 11.00
Acute heart failure: death risk higher than heart attack but care lags 30 years behind

Christian Mueller (Basel, CH)

11.00 – 11.15
Discussion

11.15 – 11.45

State of the Art Lecture

Chairpersons: Thomas Kahan (Stockholm, SE), Ferenc Follath (Lugano, CH), Juan Carlos Kaski (London, GB)

11.15 – 11.45
Pharmacotherapy of the future: From Molecules to genetic tools

Thomas Luescher (London, GB / Zurich, CH)

11.45 – 12.45

New Antidiabetic Drugs Improve Cardiovascular Morbidity and Mortality in Patients with Coronary Artery Disease and Diabetes
A Boehringer Ingelheim (Schweiz) GmbH Symposium

Chairpersons: Alexandre Fredenrich (Bellinzona, CH / Nice, FR ), Heinz Drexel (Feldkirch, AT), Francesco Paneni (Zurich, CH)

11.45 – 12.00
SGLT2 inhibitors: a change of paradigm in the treatment of cardiac failure in patients with Type 2 diabetes

Philippe van de Borne (Brussels, BE)

Description

SGLT2 inhibitors: a change of paradigm in the treatment of cardiac failure in patients with Type 2 diabetes

Philippe van de Borne (Brussels, BE)


Cardiovascular disease remains the foremost cause of mortality in diabetic patients. Numerous studies have been launched over the past years to ascertain cardiovascular safety of novel blood glucose control therapies in type II diabetic patients. These studies went far beyond the initial expectations of the investigators, as the medications under investigation appeared to better prevent major cardiovascular events than their comparator. As a result, here is now large body of evidence, derived from large cohorts of patients with type II diabetes, that some sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor analogs are beneficial not only for glucose control, but also reduce cardiovascular risk, prevent heart failure and protect type II diabetic patients from renal failure. As such, the EMPA-REG (empagliflozin), CANVAS (Canagliflozin), DECLARE–TIMI 58 (Dapagliflozin), LEADER (liraglutide), SUSTAIN-6 (semaglutide) trials, to name just a few, resulted in a paradigm shift in the treatment of type II diabetes: some of these medications have clearly upgraded glycemic control into a highly effective therapy to prevent macrovascular events in patients at high risk.

12.00 – 12.15
Beyond CVOT trials: SGLT2 inhibitors in Heart failure patients without diabetes

Francesco Paneni (Zurich, CH)

12.15 – 12.30
Emerging REAL-world Data versus clinical randomized trials and Type 2 diabetes guidelines

Heinz Drexel (Feldkirch, AT)

Description

Emerging REAL-world Data versus clinical randomized trials and Type 2 diabetes guidelines

Heinz Drexel (Feldkirch, AT)


Modern guidelines on cardiovascular pharmacotherapy rely primarily on randomised clinical trials. However, randomised clinical trials cannot give all answers requested by the clinician because there is a recruitment bias: many patients in our clinical practice cannot be included into randomised clinical trials due to exclusion criteria or a lack of inclusion criteria. A further point is that it is very often practically difficult to find patients for these trials, thus some segments of the population of interest may be underrepresented.

On the other hand, we have now - with modern databases from observational cohorts - very good real-world data. They obviate the recruitment bias. However, they suffer from a selection bias: physicians have certain selection criteria to prescribe the one or other drug, e.g. in a younger or older diabetes patient. Propensity scores try to obviate that problem but can do so only partially. In contrast to randomised clinical trials, which, if double blind, control for both known and unknown confounders, real-world data do only adjust for known confounders, even by propensity score matching. Also they have other methodological shortcomings.

A good example is the data we have obtained in the field of SGLT-2 inhibitors in treatment of type 2 diabetes. Three randomised clinical trials privided positive data for a number of endpoints. Between the trials it is difficult to assess what is a class effect and what is not. The reason is simple: there are no head-to-head comparisons between the different drugs. However, as a general rule we can conclude that SGLT-2 inhibitors improve aspects of heart failure and reduce renal function loss. In contrast, there are differences for mortality and morbidity data as well as for toxicity, e.g. amputation rates. Both, real-world data and data from randomised clinical trials have PROs and CONs. If both approaches lead to the same conclusion, we have an ideal situation for the clinician.

Reference: Niessner A et al. Non-insulin antidiabetes pharmacotherapy in patients with established cardiovascular disease: a position paper of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. Eur Heart J 2018; 39: 2274-2281.

12.30 – 12.45
Discussion

12.45 – 13.15

KEY LECTURE

Chairpersons: Heinz Drexel (Feldkirch, AT), Philippe van de Borne (Brussels, BE), Dennis Cokkinos (Athens, GR)

12.45 – 13.05
Cardiovascular effects of incretin-based therapies: lessons from the trials testing GLP1 RAs

Aldo Maggioni (Firenze, IT)

13.05 – 13.15
Discussion

The Emerging Role of PCSK9 Inhibitors after ACS
A SANOFI SYMPOSIUM

Chairpersons: Alberico L. Catapano (Milan, IT), Alberto Lorenzatti (Cordoba, AR), Giorgio Noseda (Mendrisio, CH), Heinz Drexel (Feldkirch, AT)

13.15 – 13.30
Tackling the residual risk

Alvaro Sosa-Liprandi (Buenos Aires, AR)

13.30 – 13.45
The emerging role of PCSK9 inhibitors after an acute coronary event: successful return after an Odyssee

François Mach (Geneva, CH)

13.45 – 14.00
Discussion

13.15 – 14.15

Lunch

14.15 – 15.15

Arterial Hypertension

Chairpersons: Isabella Sudano (Zurich, CH), Celso Amodeo (São Paulo, BR), Franco Muggli (Lugano, CH)

14.15 – 14.30
Hypertension – the many faces of systemic hypertension

Celso Amodeo (São Paulo, BR)

Description

Hypertension – the many faces of systemic hypertension

Celso Amodeo (São Paulo, BR)


Hypertension in the elderly: 2018 guidelines recommend more aggressive treatment of BP in the older and very old with emphasis on the biologic, not chronological age including concern for frailty, independence, and tolerance of medication. Lower BP target ranges are provided for treated patients based on age and specific comorbidities. The European guideline threshold for those ≥80 years, sBP is 160 mm Hg and diastolic 90 mm Hg. Preferential classes of antihypertensive drugs are calcium antagonista and diuretics but any

Hypertension in diabetes: Cardiovascular and renal protection should be a goal in the approach on such patient. The strategy for patients with diabetes should combine early detection of diabetes with identification of associated aditional risk factors as well as evaluation of target organ damage. Preventive approaches should include lifestyle modification and multi-target pharmacological intervention. The goal of BP control should be <130/80 mmHg and prevention, reduction or even normalization of albumine urine excretion with a renin angiotensin system inhibitor in association with other antihypertensive agents. Diabetic patient will have greater cardiovascular and renal risk reduction benefit if such approaches starts early.

Hypertension and black ethnicity: The morbidity and mortality of hypertension in black population far exceeds that of other groups. These diferences may be, in part, related to underlying genetic factors, but also underscorees the importance of socioeconomic barriers to care and inadequate treatment among minorities.The non compliance to drug treatment and lifestyle behavior are also important factor related to poor blood pressure control in such population.

Conclusion: Hypertension is a multifactorial disease with many facets according to person carcteristics related to age, race and comorbidities.

Therefore, the chose of therapy would depend on these caracteristics Always having in mind the need to improve compliance.

References:

  1. 2018 ESC/ESH Guidelines for the management of arterial hypertension Bryan Williams Giuseppe Mancia Wilko Spiering Enrico Agabiti Rosei Michel Azizi Michel Burnier Denis L Clement Antonio Coca Giovanni de Simone Anna Dominiczak European Heart Journal, Volume 39, Issue 33, 01 September 2018, Pages 3021–3104, https://doi.org/10.1093/eurheartj/ehy339
  2. Flack JM1, Calhoun D2, Schiffrin EL. The New ACC/AHA Hypertension Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Am J Hypertens. 2018 Jan 12;31(2):133-135. doi: 10.1093/ajh/hpx207.
  3. Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM).Bertoluci MC, Moreira RO, Faludi A, Izar MC, Schaan BD, Valerio CM, Bertolami MC, Chacra AP, Malachias MVB, Vencio S, Saraiva JFK, Betti R, Turatti L, Fonseca FAH, Bianco HT, Sulzbach M, Bertolami A, Salles JEN, Hohl A, Trujilho F, Lima EG, Miname MH, Zanella MT, Lamounier R, Sá JR, Amodeo C, Pires AC, Santos RD. Diabetol Metab Syndr. 2017 Jul 14;9:53. doi: 10.1186/s13098-017-0251-z. eCollection 2017
14.30 – 14.45
Target blood pressure in patients at high cardiovascular risk

Thomas Kahan (Stockholm, SE)

Description

Target blood pressure in patients at high cardiovascular risk

Thomas Kahan (Stockholm, SE)


Background
Recent discussions on hypertension management focus on optimal target blood pressure values in people according to risk. The release of new American and European guidelines on hypertension in 2017 and 2018 are thus of interest [1,2].

Current European guidelines [1] recommend a threshold of 140/90 mm Hg for starting drug treatment; 160/90 mm Hg in people 80 years or older. In very high risk people drug treatment may be considered already with a systolic blood pressure of 130 mm Hg or higher. Treatment to a target of 130-140/70-80 mm Hg (if tolerated) is recommend in all patients, with no upper age limit, including patients with coronary artery disease, chronic kidney disease, diabetes mellitus, or a history of transitory ischemic attack/stroke. In patients 65 years or younger, however, a target of 120-130/70-80 mm Hg (if tolerated) is recommended, including patients with cardiovascular comorbidities or diabetes. This does not include chronic kidney disease, since support from outcome studies was considered insufficient; but that view has been challenged [3]. A low diastolic blood pressure should not prevent further reducing pressure to reach systolic blood pressure target. Target blood pressure in chronic heart failure is less well established but 120-40/70-90 mm Hg is recommended. However, all patients with left ventricular hypertrophy should aim for 120-130/70-80 mm Hg. In patients with marked left ventricular dysfunction achieved blood pressure may be even lower because of the desirability to remain on treatment with target doses of guideline directed heart failure medications. This should be continued, if tolerated, because of their well documented protective effects.

Current American guidelines [2] now define hypertension as a blood pressure of 130/80 mm Hg or higher. They recommend starting antihypertensive treatment with drugs in all adults with 140/90 mm Hg or higher, and with 130/80 mm Hg or higher in people with atherosclerotic cardiovascular disease or a 10 year risk of cardiovascular morbidity of 10 % or more. Recommended target blood pressure is below 130/80 mm Hg, including older age (taking due consideration to comorbidity, frailty, and clinical judgement) and patients with coronary artery disease, chronic heart failure, chronic kidney disease, diabetes mellitus, or a history of transitory ischemic attack/stroke. Extensive supplemental documentation [4] suggest no important benefit in lowering blood pressure below 120/70 mm Hg, in agreement with the European recommendation of target blood pressure interval [2].

Conclusion
Compared to previous guidelines, current American and European guidelines share many similarities and recommend lower target blood pressure (120-130/70-80 mm Hg) for many patients, including high risk patients.

  1. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2018;138(17):e484-e594
  2. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36(10):1953-2041
  3. Reboldi G, Gentile G, Angeli F, Verdecchia P. The 2018 ESC/ESH hypertension guidelines: Should nephrologists always stop at the lower boundary? J Nephrol. 2018;31(5):621-626
  4. Reboussin DM, Allen NB, Griswold ME, Guallar E, Hong Y, Lackland DT, Miller EPR 3rd, Polonsky T, Thompson-Paul AM, Vupputuri S. Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e595-e616
14.45 – 15.00
Antihypertensive treatment in the very elderly

Georg Noll (Zurich, CH)

15.00 – 15.15
Discussion

15.15 – 15.40

ASPIRIN IN PRIMARY PREVENTION: A PARADIGM CHANGE?

Chairpersons: Antoni Martinez-Rubio (Barcelona, ES), Mauro Capoferri (Chiasso, CH), Hector Ventura (Miami, US)

15.15 – 15.30
Aspirin for Primary Prevention in the Elderly: Lessons from ASPREE

John McNeil (Melbourne, AU)

Description

Aspirin for Primary Prevention in the Elderly: Lessons from ASPREE

John McNeil (Melbourne, AU)


Background:
The efficacy of low-dose aspirin for the secondary prevention of cardiovascular disease has been established in a series of randomised clinical trials dating from the early 1970s. Subsequent primary prevention trials suggested similar efficacy for individuals free of cardiovascular disease. As a result low-dose aspirin has become widely prescribed for otherwise healthy individuals perceived to be at high risk of heart disease. Data from the US have suggested that up to 40% of eligible individuals take daily aspirin for this purpose. Since about 2000 additional primary prevention trials with aspirin have been published where the results have been less consistent, leading to the establishment of three more definitive trials, all three of which were published in the latter half of 2018. The ASCEND trial focussed on aspirin for primary prevention in diabetics, the ARRIVE trial in patients at moderately high CVD risk, and the ASPREE trial on the elderly. The results were uniformly unimpressive, with higher rates of bleeding that appeared to negate any cardiovascular benefit. The outcome in the ASPREE trial was disability-free survival, a composite of survival free of disability or dementia which was also unaffected by aspirin. A higher mortality rate amongst the elderly participants in that trial , due mainly to an increased mortality from cancer , was unexpected and may be specific to an elderly population.
Given the new evidence, the AHA/ACS guidelines for the use of aspirin were recently revised and the recommendation for aspirin use in individuals aged 70 years and above , was altered from ‘efficacy unknown’ to ‘low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.

Conclusion:
Recent clinical trials have raised doubts about the value of prescribing low-dose aspirin for primary prevention of CVD, especially amongst individuals aged 70yrs and older

References

Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019 Mar 17:CIR0000000000000678. doi: 10.1161/CIR.0000000000000678. [Epub ahead of print]

ASCEND Study Collaborative Group, Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G, Barton J, Murphy K, Aung T, Haynes R, Cox J, Murawska A, Young A, Lay M, Chen F, Sammons E, Waters E, Adler A, Bodansky J, Farmer A, McPherson R, Neil A, Simpson D, Peto R, Baigent C, Collins R, Parish S, Armitage J. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. . N Engl J Med. 2018 ;379(16):1529-1539

Gaziano JM1, Brotons C2, Coppolecchia R3, Cricelli C4, Darius H5, Gorelick PB6, Howard G7, Pearson TA8, Rothwell PM9, Ruilope LM10, Tendera M11, Tognoni G12; ARRIVE Executive Committee. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392(10152):1036-1046.

McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR, Reid CM, Lockery JE, Kirpach B, Storey E, Shah RC, Williamson JD, Margolis KL, Ernst ME, Abhayaratna WP, Stocks N, Fitzgerald SM, Orchard SG, Trevaks RE, Beilin LJ, Johnston CI, Ryan J, Radziszewska B, Jelinek M, Malik M, Eaton CB, Brauer D, Cloud G, Wood EM, Mahady SE, Satterfield S, Grimm R, Murray AM; ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 379:1509-1518.

15.30 – 15.40
Discussion

15.40 – 16.20

Ventricular and atrial remodeling - the road to heart failure: future approaches.
A joint Session with the French Society of Cardiology

Chairpersons: Antoni Martinez-Rubio (Barcelona, ES), Gheorghe Dan (Bucharest, RO), Dennis Cokkinos (Athens, GR), Stefano Muzzarelli (Locarno, CH)

15.40 – 15.55
Cardiac remodeling in metabolic cardiomyopathy

Geneviève Derumeaux (Créteil, FR)

Description

Cardiac remodeling in metabolic cardiomyopathy

Geneviève Derumeaux (Créteil, FR)


Metabolic abnormalities such as type 2 diabetes mellitus (T2DM), obesity, and metabolic syndrome have an impact cardiovascular system including the development of disturbances of cardiac rhythm, function, and structure1. Indeed T2DM and obesity are important contributors to non-ischemic heart failure (HF: 2- to 5-fold increase in HF associated with T2DM) and atrial fibrillation (6% increase per unit increase in body mass index.

Using preclinical data2 and analysis of on-going well phenotyped cohorts3 our aim is to better understand the relationship between metabolic derangements, associated measures of cardiac function and morphology, and the future occurrence of heart failure and cardiovascular events. In particular we will focus on the progression of myocardial fibrosis4—one of the key mechanisms underlying cardiac dysfunction and will discuss its relationships with metabolic, pro-inflammatory and neuro-hormonal factors.

Metabolic cardiomyopathy leads to a number of changes in cardiac structure and function that can be recognized by imaging in the asymptomatic phase, and these parameters can be used for monitoring the progression of disease or the response to therapy. Therefore we will emphasize the significance of nonconventional echocardiographic methods, especially systolic left ventricular longitudinal deformation assessment (strain imaging or speckle tracking imaging), in identifying the individuals that may be at risk of the progression of preclinical impairment to symptomatic disease, as well as more likely to benefit from behavioural and pharmacological interventions5. Furthermore we will review the role of cardiac magnetic resonance in the recognition of asymptomatic metabolic cardiomyopathy, the monitoring of pathological alterations and of potential responses to therapy6.

References:

  1. Kosmala W et al. Subclinical Myocardial Impairment in Metabolic Diseases. J Am Coll Cardiol Img 2017;10:692–703
  2. Ternacle J et al. Short-term high-fat diet compromises myocardial function: a radial strain rate imaging study. Eur Heart J Cardiovasc Imaging. 2017;18:1283-1291
  3. Ernande L et al. Clinical Implications of Echocardiographic Phenotypes of Patients With Diabetes Mellitus. J Am Coll Cardiol. 2017;70:1704-1716.
  4. Sawaki D et al. Visceral Adipose Tissue Drives Cardiac Aging Through Modulation of Fibroblast Senescence by Osteopontin Production. Circulation. 2018 Aug 21;138(8):809-822.
  5. Ernande L, et al. Longitudinal myocardial strain alteration is associated with left ventricular remodeling in asymptomatic patients with type 2 diabetes mellitus. J Am Soc Echocardiogr 2014;27:479–88.
  6. Jellis CL, et al. Biomarker and imaging responses to spironolactone in subclinical diabetic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2014;15:776–86.
15.55 – 16.10
Left ventricular architecture, long-term reverse remodeling and clinical outcome: lessons from the REVERSE trial

Jean-Claude Daubert (Rennes, FR)

Description

Left ventricular architecture, long-term reverse remodeling and clinical outcome: lessons from the REVERSE trial

Jean-Claude Daubert (Rennes, FR)


Reverse ventricular remodeling with sustained decrease in left ventricular volumes, usually associated with an increase in LVEF is one of the most relevant long-term effects of cardiac resynchronization therapy (CRT). The beneficial effect on LV anatomy and function is possibly related to correction of the myocardial protein dysregulation induced by LV dyssynchrony (Spragg, Kass). It has been shown in animal models of dyssynchronous heart failure (HF) that CRT correct myocardial gene expression heterogeneity (Bart, Kass). The clinical efficacy of CRT has been demonstrated in large scale randomized clinical trials in HF patients with reduced LVEF and wide QRS, who remained symptomatic in NYHA functional class II-IV despite optimized pharmacological treatment (COMPANION, CARE HF, REVERSE, MADIT CRT, RAFT). In mildly symptomaic patients, the treatment goal is prevention of HF progression. Most trials included a sequential echocardiographic study with centralized data analysis. Only one, the REVERSE trial had a key powered secondary endpoint of reverse remodeling (change in LVESVi). REVERSE included 610 NYHA class I-II after successful implantation of a CRT device (Linde, Daubert). Patients were randomized 2 :1 to CRT ON or CRT OFF for 12 (US) or 24 (EU) months, then followed prospectively up to 5 years. Echos were analyzed by two core centers.

During the randomized period, LVESVi decreased significantly (mean absolute change=26.9 ml/m2, or 28%) in the CRT ON group when it remained stable in the CRT OFF group. Decrease was progressive up to 18 months then stabilized thereafter. Similar changes were observed for the end-diastolic volume. Long-term follow-up in CRT ON patients showed continuation of the positive effect with stabilization of LV volumes up to 5 years. In parallel, LVEF increased by a mean of 6% before stabilizing after two years.

The prognostic impact of reverse remodeling was shown by a lower mortality rate (HR 0.32 (0.17, 0.63), P= 0.0004) and a lower risk of new VT-VF event (HR 0.31 (0.15-0.61), P>0.001) at 5-yrs in patients with LVESVi reduction > 15% compared to patients with LVESVi increase or decrease < 15%.

In conclusion : after CRT, reverse remodeling occurs in a majority of patients (70-80%). The process is progressive and needs 12-18 months to be completed. Reverse remodeling is associated with better outcomes, in particular lower mortality rates

16.10 – 16.20
Discussion

16.20 – 16.35

ISCP Awards

Augusto Gallino (Bellinzona, CH), Juan Carlos Kaski (London, GB)

16.20 – 16.30
ISCP Posters Awards

16.30 – 16.35
Announcement of the 2020 ISCP annual meeting Miami

Hector Ventura (Miami, US)

16.35

End of the meeting