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FINAL PROGRAMME AND ABSTRACT BOOK

2nd European-Middle East Forum on“Managing cardiovascular risk factors in clinical practice”6 December, 2013 - Istanbul, Turkey

FINAL_PROGRAMME_ISTANBUL_281013.indd 1 03/12/2013 09:04:32

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General information

VenueHilton Istanbul HotelCumhuriyet Caddesi HarbiyeIstanbul, Turkey

LanguageThe official language of this course will be English

Scientific secretariatSerono Symposia International FoundationSalita San Nicola da Tolentino 1/b – 00187 Rome, ItalyAssociate Project Manager: Dorina MonacoSpecialist Medical Advisor: Davide MineoPhone: +39-06-420413 314 – Fax: +39-26-420413 677E-mail: [email protected] Symposia International Foundation is a Swiss Foundation with headquarters in 14, rue du Rhône, 1204 Geneva, Switzerland

Organizing secretariatMeridiano Congress InternationalVia Mentana, 2/B | 00185 Rome, Italy

Congress Coordinator: Concetta Di PalmaTel.: +39 06 88595 226 Fax: +39 06 88595 234E-mail: [email protected]


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Background and aims of the conferenceCardiovascular diseases are the main cause of morbidities and mortality worldwide, and the related risk factors, such as diabetes, dyslipidemia, obesity and sedentary, are particularly increasing in developing countries changing towards a western life-style. This is also true in the Middle East nations, representing an emergency for their healthcare professionals and healthcare systems.Hypertension and its complications, such as heart failure, cerebrovascular events and atrial fibrillation, are mainly responsible for disabilities and numerous deceases. The implementation in clinical practice of a modern management approach is crucial, with both prevention and intervention strategies required to improve patient care while balancing the related socio-economic burden.Serono Symposia International Foundation is organizing the 2nd European-Middle East forum on “Managing Cardiovascular Risk Factors in Clinical Practice” to provide physicians dealing with patients having cardiovascular risk factors or diseases with a common stand where to compare and share experiences in this field, led by key experts from Europe and the Middle East regions.The aims of this event are to deliver updated knowledge on the main aspects of prevention and management of the major cardiovascular risk factors and diseases, and to give insights on particular cardiovascular complications and case presentations according to current guidelines and evidence-based medicine, thus improving the skills in clinical practice of participants and ultimately patient care.

Learning objectivesParticipants, after attending this live educational event, by receiving updated knowledge on cardiovascular risk factors and diseases, will be able to:

1. Evaluate the impact of the different cardiovascular risk factors on patients and implement appropriate counteracting interventions2. Manage hypertension and related cardiovascular complications, such as heart failure, cerebrovascular events and atrial fibrillation3. Use the right diagnostic and therapeutic strategies in clinical practice to face difficult cases, including those with poor treatment adherence

Target audienceCardiologists, internists, general practitioners and the all other physicians involved in the prevention and management of patients with cardiovascular risk factors or having cardiovascular diseases.

All Serono Symposia International Foundation programs are organized solely to promote the exchange and dissemination of scientific and medical information. No forms of promotional activities are permitted. This program is made possible thanks to an educational grant received from Merck Serono Middle East.

2nd European-Middle East Forum on“Managing cardiovascular risk factors in clinical practice”


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AccreditationThe event “2nd European-Middle East Forum on “Managing cardiovascular risk factors in clinical practice” is accredited by the European Board for Accreditation in Cardiology (EBAC) for six (6) hours of External CME credits. Each participant should claim only those hours of credit that have actually been spent in the educational activity. EBAC works according to the quality standards of the European Accreditation Council for Continuing Medical Education (EACCME), which is an institution of the

European Union of Medical Specialists (UEMS).”

SSIF adheres to the principles of the Good CME Practice group

This programme is endorsed by:

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Good

C M E Practice

We value your opinion!We are continually trying to develop and improve our educational initiatives to provide you with cutting-edge learning activities.During this conference you will be asked to answer a real-time survey and after this educational event you will be receiving an online survey to help us to better tailor our future educational initiatives.We thank you for participating!

MHypertension

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Scientific organiser

Giuseppe A. ManciaUniversity of Milano Bicocca, Istituto Auxologico Italiano IRCCS and Centro di Fisiologia Clinica e Ipertensione Milan, Italy

Scientific committee

Giuseppe A. ManciaUniversity of Milano Bicocca, Istituto Auxologico Italiano IRCCS and Centro di Fisiologia Clinica e Ipertensione Milan, Italy

Antonio Coca Hospital Clínic University of Barcelona Hypertension and Vascular Risk UnitInstitute of Internal Medicine and DermatologyBarcelona, Spain

Roberto Ferrari Department of CardiologyUniversity Hospital of FerraraFerrara, Italy

Wael Al Mahmeed Sheikh Khalifa Medical CityDepartment of CardiologyAbu Dhabi, United Arab Emirates

Maurice Khoury Division of Cardiology Department of Internal Medicine American University of Beirut-Medical Center Beirut, Lebanon


Faculty list


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Kadhim Sulaiman

Department of CardiologyMuscat, Sultanate of Oman

Athanasios Manolis

Cardiology DepartmentAsklepeion HospitalAthens, Greece

Ali Abu-Alfa

American University of Beirut Faculty of Medicine Department of Internal Medicine Division of Nephrology and HypertensionBeirut, Lebanon

Peter Nilsson

Lund University, University Hospital Department of Clinical Sciences Malmö, Sweden

Enrico Agabiti Rosei

Clinica Medica and Department of Clinical and Experimental Sciences University of BresciaDepartment of MedicineAzienda Ospedali Civili Brescia, Italy

Mohamed Ayman SalehCardiology and Vascular medicineAin Shams University Medical SchoolCairo, Egypt

Mouaz H. Al-MallahWayne State University, Detroit, MI, USA andCardiologist and Division Head, Cardiac ImagingKing Abdul-Aziz Cardiac CenterKing Abdul-Aziz Medical City Riyadh, Kingdom of Saudi Arabia

Nooshin BazarganiCardiologyDubai United Arab Emirates

List of Faculty Members

Giuseppe A. Mancia

University of Milano Bicocca, Istituto Auxologico Italiano IRCCS and Centro di Fisiologia Clinica e Ipertensione Milan, Italy

Wael Abdulrahman Al Mahmeed

Sheikh Khalifa Medical CityDepartment of CardiologyAbu Dhabi, United Arab Emirates

Maurice Khoury

Division of Cardiology

Department of Internal Medicine

American University of Beirut-Medical Center

Beirut, Lebanon

Roberto Ferrari

Department of CardiologyUniversity Hospital of FerraraFerrara, Italy

Alberto Coca

Hospital Clínic University of Barcelona Hypertension and Vascular Risk UnitInstitute of Internal Medicine and DermatologyBarcelona, Spain

Guido Grassi

Medical Clinic Milano-Bicocca UniversityMilan, Italy

Alessandro Salustri

Institute of Cardiac SciencesSheikh Khalifa Medical CityAbu Dhabi, United Arab Emirates

Adel Khalifa Hamad

Department of CardiologyBahrain Defence Force Hospital – Mohammed bin Khalifa Al Khalifa Cardiac CentreMuharraq, Bahrain


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Scientific programmeFriday - 6 December, 2013

08.45

14.40

15.30 Coffee break

09.00

11.00

Session I

Session II

Hypertension as a main risk factor

Hypertension-related cardiovascular complications

Opening and IntroductionGiuseppe Mancia (Italy)

L9: Evidences and controversies in lifestyle changes for cardiovascular protection Mohamed Ayman Saleh (Egypt)

Friday - 6 December, 2013

L1: Following the route of the ESH/ESC 2013 guidelines for hypertension management Giuseppe Mancia (Italy)

L2: When sympathetic hyperactivity drives to the wrong way Guido Grassi (Italy)

L3: Breaking the cardiovascular continuum by cardio-protective agents Nooshin Bazargani (UAE)

Questions and answers

L4: Managing heart failure through current international recommendations Alessandro Salustri (UAE)

L5: Protecting from cerebrovascular event and related cognitive dysfunction and dementia Antonio Coca (Spain)

L6: Modern management of atrial fibrillation, from blood pressure control to anti-coagulation Adel Khalifa (Bahrain)


09.20

11.20

10.30 Coffee Break

12.30 Lunch Break

09.40

11.40

Chairman: Maurice Khoury (Lebanon)

Chairman: Antonio Coca (Spain)

16.15

17.30

Session IV

Session V

From theory to practice workshops: improving daily clinical care

L10: Resistant hypertension, from medical therapy to interventional strategies Athanasios Manolis (Greece) Ali K. Abu-Alfa (Lebanon)

L11: Bioimaging approach to the diagnosis of vascular disease in hypertension Enrico Agabiti Rosei (Italy) Mouaz H. Al-Mallah (Kingdom of Saudi Arabia)


Panel discussion on adherence to treatmentfrom the Scientific Committee

Summary of lectures and take-home messages

Closing remarksGiuseppe Mancia

16.30

18.15

18.30

Chairman: Roberto Ferrari (Italy)

Roundtable on adherence to treatment and conclusions

10.00

16.00

16.45

12.00

17.00

15.00 Questions and answers

14.00

Session III Cardiovascular risk factors: more challenges to face

L7: The burden of the cardio-metabolic disease in the Middle East countries Kadhim Sulaiman (Oman)

L8: Sleep apnea and cardiovascular disease Peter Nilsson (Sweden)

14.20

Chairman: Wael Al Mahmeed (UAE)


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Disclosure of faculty relationships

Peter M Nilsson declared no potential conflict of interest

Enrico Agabiti Rosei declared no potential conflict of interest

Ali Abu-Alfa declared no potential conflict of interest

Adel Khalifa declared receipts of honoraria or consultation fees from Boehringer Ingelheim

Mouaz Al-Mallah declared receipts of honoraria or consultation fees from GE Healthcare. Declared to be member of company advisory board, board of directors or other similar groups of: GE Healthcare

Roberto Ferrari declared receipts of research grants and contracts from: Boehringer Ingelheim, Novartis, Roche, Servier . Declared receipts of honoraria or consultation fees from: Advisory Board Bayer, Boehringer Ingelheim, Roche, Servier. Declared participation in a company sponsored speaker’s bureau of: Boehringer Ingelheim, Roche, Servier.

Guido Grassi declared no potential conflict of interest

Giuseppe Mancia declared no potential conflict of interest

Antonio Coca declared no potential conflict of interest

Mohamed Ayman Saleh declared no potential conflict of interest

Alessandro Salustri declared no potential conflict of interest

Kadhim Jaffer Sulaiman declared no potential conflict of interest

Athanasios Manolis declared no potential conflict of interest

Nooshin Bazargani declared no potential conflict of interest

Wael Al Mahmeed declared no potential conflict of interest

The following faculties have provided non information regarding significant relationship with commercial supporters and/or discussion of investigational or non –EMEA/FDA approved (off-label) uses of drugs as of 21 November 2013:

Maurice Khoury


Abstract


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Giuseppe Mancia, University of Milano Bicocca, Istituto Auxologico Italiano IRCCS and Centro di Fisiologia Clinica e Ipertensione, Milan, Italy

This presentation will focus on a number of new key diagnostic aspects of the recent guidelines on hypertension of the European Society of Hypertension and the European Society of Cardiology. Mention will be made of the role of out-of-office blood pressure (BP) in the identification of hypertensive patients as well as in the assessment of the efficacy of treatment, with emphasis on the valuable information this approach may provide but also on its current limitations. The importance of quantifying total cardiovascular risk in hypertensive patients will then be discussed, with mention that this quantification should include measures of asymptomatic organ damage. Several issues related to treatment will then be addressed. One, the BP threshold at which antihypertensive drugs should be administered. Two, the BP target to be reached with treatment. Three, the most suitable drugs and treatment strategies to achieve treatment goals. The last issue will include a discussion also of the best possible combinations of drugs as well as whether and when combination treatment can be considered as the initial treatment step.

L1 - Following the route of the ESH/ESC 2013 guidelines for hypertension management


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L2 - When sympathetic hyperactivity drives to the wrong

Guido GrassiClinica Medica, Ospedale San Gerardo dei Tintori, Monza and Dipartimento di Medicina Clinica, Prevenzione e Biotecnologie Sanitarie, Università Milano-Bicocca, Milan, Italy.

The sympathetic nervous system exerts a key role in the homeostatic control of the cardiovascular system by regulating cardiac output directly and, peripheral vascular resistance and blood pressure indirectly. In addition sympathetic neural factors are involved in the control of the glucose and lipid metabolism, of the immune reaction as well as of the neurohumoral modulation of the circulation. In a number of cardiovascular (hypertension, acute myocardial infarction, congestive heart failure), metabolic (diabtes mellitus, obesity, metabolic syndrome), heptic (cirrhosis) and renal (renal failure) disease, the sympathetic cardiovascular influences undergo a marked potentiation. In several instances this adrenergic stimulation occurs early in the clinical course of the disease and has a compensatory function. A classic example is represented by the sympathetic activation characterising the heart failure syndrome, which is already evident in NYHA class I and II and is aimed, in the initial clinical stages of the disease, at maintaining adequate perfusion to different organs despite the impairment in cardiac pump function. With the disease progression, however, the hyperadrenergic state is a factor further aggravating the disease and affecting in an unfavourable fashion the disease prognosis. This is true not only in heart failure but also in renal insufficiency and in hypertension, in which sympathetic neural factors are responsible, together with the haemodynamic overload, for the structural and functional alterations of the heart and large vessels as well.This presentation will review the role of the sympathetic nervous system in cardiovascular disease, discussing the main detrimental effects of the adrenergic activation on cardiometabolic function.


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Nooshin BazarganiCardiology, Dubai United Arab Emirates

L3 - Breaking the cardiovascular continuum by cardio-protective agents

Abstract not in hand at the time of printing.


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Alessandro Salustri Sheikh Khalifa Medical City – Abu Dhabi (U.A.E.)

L4 - Managing heart failure through current international recommendations

The management of patients with chronic heart failure is a challenging problem in all countries. The development of new drugs and the availability of sophisticated electrical devices have significantly prolonged the life expectancy of patients with heart failure, with an impact on the need for adequate follow-up visits. In addition, the proper treatment of patients with heart failure involves different specialties (cardiologist, nephrologist, respirologist, diabetologist, internal medicine, clinical pharmacist, dietician, nurses, physiotherapist) requiring an integrated and coordinated approach. Moreover, titration of drugs is often required, which needs frequent follow up visits for proper adjustment of medication.The ‘Heart Failure Clinic’ is a model of care based on a multidisciplinary, team-oriented approach for patients with chronic heart failure, with the aim of achieving comprehensive management and close monitoring of these patients. Previous experience has shown a significant reduction in the number of hospital readmission in patients with chronic heart failure followed in a dedicated heart failure clinic.International guidelines are easily available and would help in setting up a heart failure clinic. Standards of care can be identified and applied to these models. However, geographic, demographic, logistic, and cultural differences among different countries should be considered when planning for a heart failure clinic. The heart failure clinic at Sheikh Khalifa Medical City in Abu Dhabi was started in 2011 and is currently running with all the specialties previously described, under the supervision of a dedicated cardiologist. The following aspects are relevant to our practice:

1- Demographics: only 16% of the UAE population is local. Among non-locals, South Asian (Indian, Pakistani, Bangladeshi) constitutes the largest group, making up 58% of the total; other Asians makes up 17% while Western expatriates are 9% of the total population.

2- Geographics: most of the UAE territory is desert and the temperatures in summer are extremely high, which may hamper the availability for regular follow up visits.

3- Drug compliance: although the access to healthcare in general is easy, the refill rate is sometimes low, with gaps in the pharmacological treatment.

While it is important to follow the international guidelines and recommendations, it is also crucial to put the heart failure clinic into the local context in order to minimise the effects of the potentially negative factors.


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L5 - Protecting from cerebrovascular events and related cognitive dysfunction and dementia

Antonio Coca MD, PhD, FRCPHypertension and Vascular Risk Unit. Institute of Internal Medicine and Dermatology. Hospital Clínic (IDIBAPS).University of Barcelona, Barcelona, Spain

Stroke is one of the major causes of mortality and disease burden in Europe and worldwide because of residual disability and cognitive decline. The benefits of reducing blood pressure (BP) on stroke are widely recognised, although no conclusive evidence is available on the optimal level to which BP should be reduced. The concept that the lower the BP achieved the greater the outcome reduction has often been challenged by the hypothesis that a J-shaped relationship exists between BP achieved by treatment and incident cardiovascular events, such as stroke recurrences. So far no prospective study was designed to explore the ideal BP targets in secondary stroke prevention. The ESH-CHL-SHOT trial (Stroke in Hypertension Optimal Treatment trial) promoted by the European Society of Hypertension (ESH) and the Chinese Hypertension League (CHL) is addressing this issue. The study started very recently and the results are expected by 2018. In addition, high BP has also been implicated in the development of cognitive dysfunction and vascular dementia in elderly patients. Hypertension induces long-term remodeling and endothelial dysfunction in the brain arteries and subclinical damage (white matter lesions-WML, microbleeds, lacunae) may be detected using cerebral magnetic resonance imaging (MRI). Several studies have examined the relationship between WML severity and cognitive decline over time and found that subjects with severe periventricular WML had more rapid cognitive decline. Our group found an association between WML in brain MRI and poorer neuropsychological test results in middle-aged, asymptomatic, never-treated essential hypertensive patients. In this sense, results from cross-sectional and longitudinal studies have shown a correlation between BP and WML and cognitive function in the elderly. In addition, there is some evidence that antihypertensive drug treatment could play a role in the prevention of cognitive impairment or vascular dementia through BP control. Only two observational studies and a meta-analysis suggest that prevention of white matter lesions progression and cognitive decline by lowering BP is possible, but this suggestion requires verification in large randomised clinical trials including appropriate cognitive endpoints. In summary, current evidence supports the view that hypertension in mid-life, especially if not treated effectively, negatively affects cognition and contributes to the development of dementia in late life. High BP in the middle-aged implies a long-term cumulative effect leading to increased severity of atherosclerosis and more vascular co-morbidities in late life.


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Adel Khalifa Hamad

Department of Cardiology Bahrain Defence Force Hospital – Mohammed bin Khalifa Al Khalifa Cardiac Centre Muharraq, Bahrain

L6 - Modern management of atrial fibrillation, from blood pressure control to anti-coagulation

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice. Studies have shown that the prevalence of AF increases with age from almost 4% in those above the age of 60 years to almost 10% in octogenarians. AF is not a simple disease: it is a syndrome and associated with high morbidity and mortality. Not only that, in the next few years we will see a growing epidemic of AF. One of the most devastating complications of AF is stroke, which has significant disability compared to stroke without AF. Warfarin has been the gold standard for stroke prevention in patients with high risk factors, however it is cumbersome to use and has many disadvantages. Recently, newer anticoagulants have appeared in clinical practice. These agents are non-inferior to warfarin and some of them are superior in terms of stroke reduction. Overall, there have been tremendous advances in the management of AF in the past few years from pharmacotherapy to ablation techniques. In this presentation there will a review of recent advances in AF management.


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Kadhim Sulaiman

Department of Cardiology - Muscat, Sultanate of Oman

L7 - The burden of the cardio-metabolic disease in the Middle East countries

Abstract not in hand at the time of printing.


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Peter Nilsson Obstructive Sleep Apnoea (OSA) and cardiovascular diseasePeter M Nilsson, Dept. Clinical Sciences, Lund University, University Hospital, Malmo, Sweden, mail [email protected]

OSA is a prevalent cardiovascular risk factor and associated with resistant hypertension as well as insulin resistance and metabolic disturbances [1]. Many risk factors that cluster within the metabolic syndrome are also associated with OSA. As OSA is more prevalent in men than in women this could contribute to the increased cardiovascular risk seen in men. The treatment of OSA includes weight reduction and control of conventional cardiovascular risk factors by lifestyle interventions or drug therapy. A technical intervention with some benefits is the continuous positive airway pressure (CPAP) technology. In randomised studies it has been possible to see favourable effects on blood pressure levels following CPAP treatment based on a meta-analysis [2], especially in subjects with frequent apnoeic episodes, but harder to show benefits on glucose metabolism even if insulin secretion may improve. In compliant, non-sleepy hypertensive patients with OSA a 3-year long treatment with CPAP was, however, not more successful for blood pressure control than in non-compliant study participants [3]. A new technical intervention is renal nerve ablation for the reduction of sympathetic nervous activity. In a pilot study this kind of intervention was also successful in reducing the frequency of apnoeic episodes during sleep. This effect has to be tested and confirmed in lager randomised studies [4].In summary, OSA is an important cardiovascular risk factor and responsible for many cases of resistant hypertension. Modern treatment of OSA should include weight control, risk factor treatment and CPAP devices. In some cases also renal nerve ablation could represent an attractive intervention if resistant hypertension is also present.

References:

1 - Parati G, Lombardi C, Hedner J, Bonsignore MR, Grote L, Tkacova R, et al; European Respiratory Society; EU COST ACTION B26 members. Position paper on the management of patients with obstructive sleep apnea and hypertension: joint recommendations by the European Society of Hypertension, by the European Respiratory Society and by the members of European COST (COoperation in Scientific and Technological research) ACTION B26 on obstructive sleep apnea. J Hypertens. 2012;30:633-46.2 - Fava C, Dorigoni S, Dalle Vedove F, Danese E, Montagnana M, Guidi GC, et al. Effect of continuous positive airway pressure (CPAP) on blood pressure in patients with obstructive sleep apnea/hypoxia. A systematic review and meta-analysis. Chest. 2013 Sep 26. doi: 10.1378/chest.13-1115. [Epub ahead of print].3 - Kasiakogias A, Tsioufis C, Thomopoulos C, Aragiannis D, Alchanatis M, Tousoulis D, et al. Effects of continuous positive airway pressure on blood pressure in hypertensive patients with obstructive sleep apnea: a 3-year follow-up. J Hypertens. 2013;31:352-60.4- Schmieder RE, Redon J, Grassi G, Kjeldsen SE, Mancia G, Narkiewicz K, et al. ESH position paper: renal denervation - an interventional therapy of resistant hypertension. J Hypertens. 2012;30:837-41.

L8 - Sleep apnea and cardiovascular disease


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Mohamed Ayman SalehAuthors : Saleh A. Ayman ,Selim Ghada ,khorshid Hazem, Mansour Sherief , El Missiry Ahmed.Affiliation : all authors are faculty members of the cardiology department , Ain Sham University , Cairo ,Egypt.

L9 - Evidences and controversies in lifestyle changes for cardiovascular protection

Cardiovascular disease is the leading cause of death in both developed and developing countries. The classic risk factors account for 80% of the occurrence of cardiovascular disease. Atherosclerosis is a continuous process therefore the concept of primary and secondary prevention, though still valid, can be replaced by reduction of atherosclerotic burden. Lifestyle changes include physical activity/exercise training, weight control, healthy eating patterns, smoking cessation and stress management.Lifestyle change is proven to decrease the incidence of classic risk factors, to improve quality of life of patients with established cardiovascular disease and even carry a survival benefit for a subset of them. There is a general agreement about the core components of lifestyle change programs. Gaps in knowledge and points of controversy exist. Examples of these points are: the optimal mix of components of lifestyle change, the benefits and safety of exercise in high risk patients, the benefit of less than the recommended intensity and duration, whether raising the fitness of a cardiac patient (eg resistance exercise) yields less future cardiovascular risk, the relative role of diet and exercise in managing obesity, which of the components of a healthy dietary pattern is more beneficial and finally who should be responsible for implementing lifestyle changes.


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L10 - Resistant hypertension, from medical therapy to interventional strategies

Athanasios J. ManolisDirector Cardiology Department, Asklepeion General Hospital, Athens, Greece

Resistant hypertension is defined as failure to reach goal blood pressure (BP) in spite of concurrent treatment with maximum tolerated doses of three antihypertensive agents of different classes, including a diuretic. Several trials have demonstrated that achievement of BP goals is still poor despite the use of several protocol-defined treatment regimens. The exact prevalence of RH is difficult to determine and a forced titration study of a large, diverse hypertensive cohort is necessary in order to be established. In several trials 20% to 35% of participants could not achieve BP control despite receiving more than three antihypertensive medications. Numerous factors have been identified as causes of RH and are usually related to patient characteristics, accuracy of BP monitoring, antihypertensive and concomitant treatment, as well as secondary causes. In order to improve patient compliance to antihypertensive treatment physicians should prescribe simple, fewer and more effective regiments such as long acting agents and fixed-dose combinations. Fixed-dose combinations not only improve patient compliance but also decrease the incidence of drug-related side effects. They can also provide more reliable BP control due to the synergic effect of the different classes of agents contained. Volume overload is the most frequent cause of RH. Optimising or changing diuretic therapy can increase the percentage of patients that achieves target BP. For patients with true RH, there are data to support the addition of a calcium channel blocker (CCB) to a regimen that includes a RAAS blocker and a diuretic. Aldosterone is also part of the RAAS and the use of an aldosterone antagonist (spironolactone or eplerenone) can be helpful in controlling BP in patients with RH. When potassium sparing diuretics are prescribed in addition to an ACE inhibitor or an ARB, potassium levels should be closely monitored, especially in patients with impaired renal function. Alpha blockers (hydralazine or minoxidil) and combined alpha-beta receptor blockers (eg labetalol) can provide additional antihypertensive effect when added to existing regimens in patients with. Centrally acting alpha-agonists (methyldopa and clonidine) can also be effective, however tolerability issues exist and frequent dosing is a disadvantage. Minoxidil can cause hypertrichosis as well as rush, swelling of the mouth and light headedness. With minoxidil concomitant use of a beta-blocker and a loop diuretic is usually required due to reflex tachycardia and fluid retention.


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L10 - Resistant hypertension, from medical therapy to interventional strategies

Ali K. Abu-Alfa MD, FASNProfessor of Medicine and Head, Division of Nephrology and HypertensionAmerican University of Beirut, Beirut, Lebanon

This session will review the indications and use of interventional strategies aiming to reduce BP in patients with resistant hypertension. The two main recent interventions are renal artery denervation and baroreceptor stimulation. Candidacy for these procedures will be reviewed and the recently proposed ESH/ESC 2013 Hypertension guidelines in regards to the role of these interventions are listed below and will be discussed:

1- In case of ineffectiveness of drug treatment, invasive procedures such as renal denervation and baroreceptor stimulation may be considered.

2- Until more evidence is available concerning the long-term efficacy and safety of renal denervation and baroreceptor stimulation, it is recommended that these procedures remain in the hands of experienced operators and diagnosis and follow-up restricted to hypertension centers.

3- It is recommended that the invasive approaches are considered only for truly resistant hypertensive patients, with clinic values ≥160 mmHg SBP or ≥110 mmHg DBP and with BP elevation confirmed by ABPM.


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L11 - Bioimaging approach to the diagnosisof cardiovascular disease

A vast array of non-invasive imaging modalities is available for evaluating the presence and severity of coronary artery disease. Choosing the right test for an individual patient can be challenging but is important to proper patient diagnosis and management. At present, available tests include: myocardial perfusion imaging (MPI) (single photon emission tomography (SPECT) and positron emission tomography (PET)), stress echocardiography (ECHO), CT coronary angiography (CTA), and cardiac magnetic resonance imaging (CMR). Selection of the most appropriate imaging modality requires knowledge of: the clinical question, the patient population (pretest probability and prevalence of disease), the strengths and limitations of a modality as well as its risks, cost and availability.

The non-invasive diagnosis of CAD can be accomplished either by assessing anatomy (visualisation of coronary artery stenosis) with CTA or CMR angiography (CMRA) or by detection of myocardial ischemia with SPECT, PET, stress CMR (perfusion and/or wall motion), and stress ECHO. Though CMR is most commonly used for functional assessment, multiparametric imaging may provide both anatomic and functional information for the diagnosis of CAD. While CTA use is primarily for assessment of coronary anatomy, it has the potential benefit of detecting non-obstructive atherosclerotic plaque before being hemodynamically significant. Similar to CMR, multiparametric imaging protocols are being developed incorporating cardiac CT perfusion that may also provide functional information which may be incremental to the anatomical diagnosis of CAD.

MPI with SPECT is widely available and commonly used for CAD detection. There have been numerous studies supporting its diagnostic accuracy. Accuracy is likely even better when using newer imaging equipment, current radiotracers, image acquisition and reconstruction techniques. Diagnostic accuracy of SPECT can be limited by soft tissue attenuation of photons. PET MPI has been demonstrated to possess superior accuracy than that of SPECT for the detection of CAD. The higher cost of PET initially limited its availability but it is rapidly gaining clinical acceptance

Mouaz H. Al-MallahWayne State University, Detroit, MI, USA and Cardiologist and Division Head, Cardiac Imaging,King Abdul-Aziz Cardiac Center King Abdul-Aziz Medical City Riyadh, Kingdom of Saudi Arabia


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NOTES


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NOTES


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Serono Symposia International Foundation has launched a website focused on hypertension and cardiovascular diseases – with the specific aim of helping to reduce the impact of this disease on the society by delivering dedicated continuing medical education for healthcare professionals.

For more information visit:www.managehypertensiononline.org

www.managehypertensiononline.org


Serono Symposia International FoundationRepresentative OfficeSalita di San Nicola da Tolentino, 1/b - 00187 Rome, ItalyT +39.06.420.413.1 - F +39.06.420.413.677Headquarters14, Rue du Rhone - 1204 Geneva, Switzerland

Improving the patient’s life through medical educationwww.seronosymposia.org

Copyright © Serono Symposia International Foundation, 2013. All rights reserved.


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