PracticeUpdate: Cardiology | Vol1 - No.2 - 2016

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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
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
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.
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.
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EXPERT OPINION
ESC 2016: Highlights from
Professor Garry Jennings
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:
• 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
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.
NEWS
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