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Conference Update

Cardiology, October 2007

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Overview

Drug eluting stents: the controversy continues

Bioabsorable stents: the next frontier

Prevention of IE: New US guidelines

Extreme exercise may not be good for the heart

EUROASPIRE data and need for lifestlye changes No place for supplements as secondary prevention in

CVD

Limited use of oral anticoagulation in Atrial

Fibrillation Stem cells: a paracrine effect in heart failure

Highlights of new European guidelines on theprevention of cardiovascular disease and management

of hypertension

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Drug Eluting Stents - The

controversy continues

Late stent thrombosis: 1% of

DES pts.

45% mortality

GRACE registry found a higher

rate of late mortality in STEMI

pts with DES than with BMS

SCAAR registry: no difference

between groups

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GRACE

Observational registry of ACS

Data on 6600 pts in 94 hospitals in 14 countries Compares outcomes DES with BMS

Subset analysis looked at outcomes of STEMI pts

Significant difference in survival between 6 months

and 2 years: 8.6% with DES and 1.6% with BMS haddied

No evidence of increased mortality in NSTEMI

Limitations:

No info on the type of DES or BMS use

Characteristics of lesions: length, calcification orbifurcation

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Bioabsorable stents: the next

frontier?

Enormous potential

Stent disappears after initial

healing Removes problem of late stent

thrombosis and need for longterm anticoagulation

Advantages:Dont show up on

CT/MRI

Cardiothoracicsurgeons:metalfree segment ifreintervention needed

2 types: polymer and metal based

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Progress study

61 patients followed for 12 months

9 followed for 28 months

Fitted with AMS(Absorbable Metallic Stent)

Mg2+ in alloy

Findings: Complete degredation of stents

Durability of results

Restoration of vasoreactivity function ofstented segment of the vessel

Are future of stenting Better data needed before use in routine practice

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Prevention of IE: New US

Guidelines IE prophylaxis for dental procedures

recommended only in: Prosthetic cardiac valves

Previous endocarditis

Unrepaired congenital heart disease

Cardiac transplants who develop cardiac

valvulopathy

Most patients with valvular heart disease are no

longer considered candidates for antibiotic

prophylaxis

http://images.google.co.uk/imgres?imgurl=http://www.telegraph.co.uk/news/graphics/2007/04/19/ndentist1.jpg&imgrefurl=http://www.telegraph.co.uk/news/main.jhtml%3Fxml%3D/news/2007/04/19/ndentist119.xml&h=320&w=320&sz=29&hl=en&start=21&um=1&tbnid=t2YmJLnk0ez6SM:&tbnh=118&tbnw=118&prev=/images%3Fq%3Ddentists%26start%3D18%26ndsp%3D18%26svnum%3D10%26um%3D1%26hl%3Den%26sa%3DN

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2) Prophylaxis recommended for all dental

procedures involving manipulation of gingival

tissue or periapical region of teeth or perforation

of oral mucosa

3) Not recommended based on increased lifetime

risk of acquiring IE

4) Not needed in GU of GI tract procedures

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Extreme exercise may not be

good for the heart Endothelial progenitor cells repair damaged endothelium

and improve endothelial function and perfusion

Adams et al., analysed blood samples from 78 healthy

marathon runners (63+/-3 years) Significant decrease in progenitor cells

Increase in WCC indicating an inflammatory responsetriggered

Further studies needed:

a) time to normalisation of levels

b)what impact it has on heart and endothelial function

http://images.google.co.uk/imgres?imgurl=http://www.gbands.co.uk/resources/WEB17richardlomas.493419.full%245B1%245D.jpg&imgrefurl=http://www.gbands.co.uk/9.html&h=383&w=250&sz=39&hl=en&start=91&um=1&tbnid=FLW2g7ZAFjQBQM:&tbnh=123&tbnw=80&prev=/images%3Fq%3Dmarathon%2Band%2Bheart%26start%3D75%26ndsp%3D18%26svnum%3D10%26um%3D1%26hl%3Den%26sa%3DN

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EUROASPIRE data

Results from 3rd EUROASPIRE study

8547 coronary patients in 8 countries

Interviewed + examined early 90s, 2000,2006/7

Obesity: rates from 25% to 38%

Central obesity: rates 42% to 54%

Smoking: Prevalence not changed

Increased in younger pts (

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Diabetes: prevalence from 17%-28%

Hypertension: no. of pts reaching target BPfrom 41% to 39%

Large in prescriptions of antihypertensives

Lipids: management much improved

Need for preventive cardiology programmes

Professional intervention by MDT for lifestyle

change

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Transapical and percutaneous

Aortic Valve Replacement Advantages: avoiding sternotomy

No extracorporeal circulation

Centre in Leipzig, 122 implanations

Used for pts at high risk for standard procedure

Indications:

symptomatic pts

Severe AS

>75 years

>24mm annulus

Suitable for standard AVR

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Results: 30 day mortality 6.5%

Compares to 20% with STS

13.8% mortality during 1st year

4.7% needed conversion to open heart surgery

Success rate >90%

At one year reoperation rate 1.6%

Actual survival 74.4%

http://images.google.co.uk/imgres?imgurl=http://www.icr-heart.com/biennial2007/AbstractLinks/Poster%20Session%20I_files/image002.jpg&imgrefurl=http://www.icr-heart.com/biennial2007/AbstractLinks/Poster%20Session%20I.htm&h=270&w=360&sz=44&hl=en&start=1&tbnid=OcORLs9jQIQkCM:&tbnh=91&tbnw=121&prev=/images%3Fq%3Dtransapical%2Bvalve%2Brepair%26gbv%3D2%26svnum%3D10%26hl%3Denhttp://images.google.co.uk/imgres?imgurl=http://www.clevelandclinic.org/heartcenter/images/innovations/2005/surginnovations1.jpg&imgrefurl=http://www.clevelandclinic.org/heartcenter/pub/history/future/default.asp%3FfirstCat%3D56%26secondCat%3D57&h=210&w=250&sz=17&hl=en&start=3&tbnid=p94dLN894F-GkM:&tbnh=93&tbnw=111&prev=/images%3Fq%3Dtransapical%2Bvalve%2Brepair%26gbv%3D2%26svnum%3D10%26hl%3Den

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Percutaneous Transfemoral

Retrograde Approach 214 Pts > 70 yrs

Valve area 85%

30 day mortality 10-12%

MI rate 1%

Limitations: difficulty using large sized valvebecause of arterial conditions

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No place for supplements

as secondary prevention in

CAD

Vitamin B supplements not justified assecondary prevention in CVD

Western Norway B-vitamin intervention trial(WENBIT)

3090 pts with CAD

Placebo, vit. B6, folic acid plus vit. B12 andcombination of 3.

Homocysteine levels by 28% in groupreceiving folate

No protective effects found

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Limited use of oral

anticoagulation in AFib 5 fold increased risk of stroke in pts with Afib

2005 Euro Heart Survey found only 67% of

eligible pts were receiving anticoagulation CHADS2 score:

Score >/= 1 - oral anticoagulation needed Congestive heart failure

Hypertension

Age >75

Diabetes mellitus

History of Stroke/TIA (2 points)

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Study in NL

1,120 pts admitted with ischaemic stroke from 2003-06

On discharge 15% with known Afib were undertreated according tothe guidelines

Estimated that 25 of 89 cases could have been prevented but 5more cases of intracranial haemorrhage

To improve the situation CHADS2 score needs to be calculated

44 on adequate antithrombotictherapy

89 Previously diagnosed

AFib

77 diagnosed on admission

163 patients

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Stem Cells: a paracrine effect in

Heart Failure? Use of stem cells to improve cardiac function in

heart failure

Paracrine effectsa)induction of angiogenesis

b)inhibition of apoptosis

c)protection from ischaemicinduced injury

Most research done in MI

Complications with stem cells in HF: established scarsand diminished homing capabilities

Promising results in recent studies (TOPCARE-CHF)

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BOOST II trial

Multicentre study with 200 pts

BOOST I: positive effects in MI

Aim: to assess effects on cardiac function

To investigate whether the beneficial effects ofstem cells are produced by paracrine mechanisms

rather than proliferating cells that generate a newmyocardium

Future?? Need to improve cell delivery, isolationand storage

Current study: penetrating the heart with USguided low energy shock waves

cytokine levelshoming capacity

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Guidelines for the Prevention of

Cardiovascular Disease

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Priorities for CVD prevention in

clinical practice Patients with established atherosclerotic CVD

Asymptomatic individuals at risk because of Multiple risk factors raised total CVD risk Diabetes type 1 and 2 with microalbulinaemia

Markedly increased single risk factors especially if associated withend organ damage

Close relatives of subjects with prematureatherosclerotic CVD or those at high risk

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Objectives of CVD prevention

Primary prevention No smoking

Healthy food choices Activity: 30mins mod exercise/day

BMI

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3) To achieve more rigorous risk factorcontrol in high risk pts (established CVD

or diabetes) BP

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Total risk CVD management: A

Key Message Management of individual components of

risk impacts on total CV risk

Thus if perfect control of RF difficult, totalrisk can be by reducing other risk factors

Aspirin recommended for all pts with

established CVD and in persons >10%SCORE risk once BP controlled

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Management of Lipids

For CVD, DM and lipid levels Dietary and exercise advice and attention to all risk

factors

Some recommend statins for all CVD and DM ptsregardless of baseline levels

SCORE risk >5%

Lifestyle advice 3 months

Reassess SCORE and lipids

>5% statins recommended

TC

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QuickTime and aTIFF (Uncompressed) decompressorare needed to see this picture.

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Antihypertensive treatment:preferred

drugs

Previous Stroke Any

Previous MI BB, ACEI, ARB

Angina pectoris BB, CA

Heart failure Diuretics, BB, ACEI, ARB,

antialdosterone agents

Atrial fibrillation

RecurrentPermanent

ARB, ACEBB, non-dihydropiridine CA

ESRD/proteinuria ACEI, ARB, loop diuretics

Peripheral artery disease CA

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LVH ACEI, CA, ARB

Asympt. atherosclerosis CA, ACEI

Microalbuminuria ACEI, ARB

Renal dysfunction ACEI, ARB

Subclinical Organ Damage

ISH (elderly) Diuretics, CA

Metabolic syndrome ACEI, ARB, CA

Diabetes Mellitus ACEI, ARB

Pregnancy CA, methyldopa, BB

Blacks Diuretics, CA

Condition

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Combinations of classes of

antihypertensives

Thiazide diuretic and ACEI

Thiazide diuretic and ARB

CA and ACEI

CA and ARB

CA and thiazide

BB and CA

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European Society of Cardiology

www.escardio.org