PracticeUpdate: Cardiology | Vol1 - No.2 - 2016

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NEWS

EXPERT OPINION

ESC 2016: Highlights from Professor Garry Jennings

EDITORIAL Managing Editor Anne Neilson anne.neilson@elsevier.com Editor Carolyn Ng carolyn.ng@elsevier.com Designer Jana Sokolovskaja j.sokolovskaja@elsevier.com SALES Commercial Manager Fleur Gill fleur.gill@elsevier.com Account manager Linnea Mitchell-Taverner l.mitchell@elsevier.com

By Garry Jennings, AM, MBBS, MD, FRCP, FRACP Professor Jennings, Chief Medical Adviser of the Heart Foundation of Australia, attended the recent 2016 ESC Congress. Here are his highlights from the meeting. Clinical trial updates:

in the New England Journal of Medicine with a supplementary editorial, the study showed that CPAP improves symptoms of sleep apnoea but not outcomes. • The DANISH trial casts doubts on previously accepted guide- lines for the use of ICDs in peo- ple with nonischaemic heart failure. • NORSTENT showed no differ- ence in outcomes in a com- parison of drug-eluting and bare metal stents. However, revascu- larisation rates over the next 2 years were less with the former. PRAGUE-18 did not detect a dif- ference between prasugrel and ticagrelor but, like a number of studies where no differences

were seen, recruitment failed to meet targets and the study was underpowered. • ENSURE-AF found that edoxa- ban was equivalent to warfarin in the prevention of stroke around the time of electrical cardioversion. • A study was presented showing that the CHADS-DS2-Vasc score for defining risk in people with atrial fibrillation overestimates the number of people with low risk. GARFIELD-AF, a new score was proposed. There was also much interest in some new drug classes including PCSK9 inhibitors, powerful LDL- cholesterol lowering agents, dual angiotension receptor blocker/

neprilysin inhibitors for heart failure, new oral anticoagulants (NOACs) and their inhibitors, and SGLT2 inhibitors for diabetes. The meeting also saw the release of important new ESC guidelines that will no doubt influ- ence Australian experts as our own guidelines are revised: re- vised atrial fibrillation guidelines recommended NOACs over war- farin; heart failure guidelines were updated; dyslipidaemia guidelines took a different line to the US in recommending statins, lifestyle for everyone with dyslipidaemia but not providing targets based on risk level; and the CVD prevention guidelines put great emphasis on the Mediterranean diet, amongst other lifestyle measures.

• The SAVE study was presented by Doug McEvoy from Flinders University in Adelaide and coor- dinated from the George Insti- tute in Sydney. This international study, with over 2000 people with moderately severe sleep apnoea, examined whether CPAP reduced cardiovascu- lar endpoints that have been shown to be associated with sleep apnoea in observational studies. The result was that CPAP reduced snoring and im- proved quality of life but had no effect on the combined cardio- vascular endpoints or on mor- tality. Blood pressure was also similar in CPAP and control sub- jects. Published simultaneously

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ESC 2016: Highlights from Professor TomMarwick

Interview with Tom Marwick, MBBS, PhD, MPH Professor Marwick, Director and Chief Executive of BakerIDI Heart and Diabetes Institute, attended the 2016 ESC Congress. He shares his highlights from the meeting. 1. DANISH: ICDs in nonischaemic heart failure

I think it’s an interesting juxtaposition that one study says “do a non-invasive CT test before an angiogram so that you can avoid doing angiography” while the other says “do a non-invasive stress test instead of using current guidelines” because, again, you can save a bunch of angiograms. It also demonstrates how we’re still really uncertain about how to use non-invasive test- ing in people with chest pain. There is still a lot of work to be done in this area and I think the emphasis here is that MRI perfusion imaging is an interesting strategy that we should probably think more about in Australia. 4. NACIAM: N-acetylcysteine with glyceryl trinitrate on infarct size This is an important Australian trial investigat- ing the free radical scavenger N-acetylcysteine. The hypothesis was that, in people having myo- cardial infarction, some of the damage from the infarct is related to free radicals. And so if you could scavenge the free radicals, either that would be of direct benefit or it would enable nitrates to be effective. The investigators found a 38% reduction in infarct size with the use of the N-acetylcysteine with glyceryl trinitrate versus glyceryl trinitrate alone. What we’ve been doing with MI has really been focused on early revascularisation for a long time, but not so much on other things we can do to try to salvage tissue. This is a nice example of such a strategy. Second, this group in Adelaide has been really imaginative about selecting agents for that purpose. It’s nice to see one of these come in with a really impactful result.

with HF requires more than monitoring – we can get huge amounts of data but there needs to be some kind of interventional strategy that arises from the interpretation of the data. These results are a reality check on what telemoni- toring has to offer – I don’t think they signal the end of telemonitoring but it needs to be thought through more carefully. 3. CE-MARC 2 and CONSERVE: diagnostic trials on imaging technologies for recognition of coronary disease Both of these were diagnostic trials on the use of new imaging technologies for the recog- nition of coronary disease, comparing combina- tions of functional testing with CT and invasive angiography. In CE-MARC-2, the authors looked at MRI or SPECT imaging for perfusion versus the current NICE guidelines (which use a probability-based approach for test selec- tion). They found that the use of a functional test reduced the need for angiography and reduced interventions. In fact, in the group that had the functional test, 8% of the subsequent angiography was unnecessary compared with 28% in the group that was guided by the NICE guidelines. So that one was a win for doing stress testing. The CONSERVE trial was a comparison between coronary CT angiography versus invasive angiography in symptomatic patients to reduce the number of negative angiograms. The study showed that if CT angiogram was performed before catheterisation, there was an 85% reduction of invasive angiography, with similar outcomes. That one was a win for CT angiography.

For me, this was the top trial presented at this year’s meeting. The DANISH study looked at primary prevention with ICDs for patients with nonischaemic heart failure. Most cardiologists have, at some stage, had some disquiet about the impact of primary prevention ICDs, espe- cially in the elderly. Many ICDs are implanted and never discharge. This Danish group, in a pragmatic clinical trial, looked at whether there was a benefit of implanting an ICD in nonis- chaemic HF with an impaired ejection fraction. The investigators reported no difference in all-cause mortality with ICD versus medical care in nonischaemic HF. This is despite the fact that ICDs reduce sudden cardiac death. The results point to the role of multi-morbidity – HF patients are very likely to have multiple diseases. The message from this study is that ICDs do not benefit older patients – the study did a subgroup analysis of patients older than 68 years – whereas it might benefit younger patients. This is contrary to current guidelines and an incredibly important observation. 2. REM-HF and MORE CARE: remote telemonitoring in heart failure The REM-HF and MORE CARE were two studies of remote telemonitoring in HF pre- sented at the ESC. The conclusions were pretty much the same: telemonitoring did not change HF outcomes. We know that telemonitoring is inexpensive, and some private insurers in the US are considering it as a means of controlling costs. Clearly, the long-term care of patients

VOL. 1 • No. 2 • 2016

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