It Is now 60 years since the EsC hosted its first European Congress of Cardiology - in London in 1952. “our own Diamond Jubilee is a really important milestone in the EsC’s history,” says programme committee chairman Professor Michael Böhm. “over the years EsC congresses have gone from strength to strength until we’re now regarded as the world’s premier conference on the science, management and prevention of CVD. the scientific excellence of our meeting now attracts a truly global audience with delegates coming from over 150 countries.” Participants in this year’s event can join in the celebration at the opening ceremony later today in Room Munich, Central Village, at 17:00. over the next five days around 32,000 delegates are expected to descend on the Messe München International Congress Centre to attend the EsC’s festival of cardiology, which features 426 sessions held in 34 lecture rooms. the research presented will include 4203 original abstract studies from investigators around the world, three Hot Line sessions (sunday, Monday, tuesday) and three Clinical & Registry update sessions (sunday, Monday, wednesday), and a basic and translational science Hot Line. For the first time this year the Clinical trial Update and registry studies have been combined into one session. “Each takes a different scientific approach, which should make for really interesting debate on the significance of the different results obtained. we expect outstanding discussions,” says Böhm. Debate on the latest data will be stimulated by the innovation of round table discussions involving international leaders in the field following each Hot Line and Update session. “the idea is to foster in-depth discussions and enable delegates to really appreciate the significance of what they’ve just heard,” says Böhm. there will also be around 70 industry sponsored satellite sessions and 200 exhibiting companies. Also of key importance will be the presentation of six new EsC guidelines

for 2012, which takes place in a general overview session tomorrow (tirana, Central Village, 08:30), and six specific guideline sessions. the new titles are on prevention, heart failure, acute MI in patients presenting with st elevation, the third universal definition of MI, valvular heart disease, and atrial fibrillation. “while the heart failure and prevention have already been presented in specialist meetings, this is the first time all the guidelines will be presented to a general audience,” says Böhm. this year Japanese groups submitted the highest number of abstract studies, but the international dimension of this congress is also reflected in 30 joint sessions staged by the EsC with international sister societies, with affiliates including China, India, Gulf countries and south America. “these mutual sessions cover fields which are of particular interest in other areas of the world,” says Böhm.

For the first time scientific sessions have been scheduled on a saturday morning, with highlights including a special track for general cardiologists and nurses (tbilisi, Central Village). there are sessions on telehealth, heart disease in women, CV prevention and CV nursing in Germany. “From delegate feedback last year we discovered that a lot of people arrive before the start of the meeting and immediately want to get stuck in,” says Böhm. EsC Congress 2012 has built upon the “village system” first introduced in 2011 in Paris, with more emphasis this year on creating better visibility. themes have been allocated to ten separate villages, each of which is clearly colour coded. Each village has three lecture rooms and a small delegate lounge. Hotlines, clinical trial updates, and guidelines which cut across all areas of cardiology, will be located in the Central Village area. Increased emphasis has been placed on the Cardiologist of tomorrow track (tbilisi Central Village, Monday 8.30), with educational sessions for young cardiologists featuring new technologies for the future of cardiology, transcatheter aortic valve implantation (tAVI), the stethoscope of the future, a session explaining non-inferiority trials, and future targets in systolic heart failure management. the Clinical Case Corner, where cardiologists under 36 get the opportunity to present cases, has been strengthened with an innovative “revolving stage”. the EsC Congress 2012 mobile app will enable delegates to navigate easily through the content of the congress and tailor it to their own needs. JF

A festival of cardiology at adiamond jubilee congress

Cardiologist interviewsand discussions

Visit UsESC Plaza25-28 Aug

www.escardio.org/esc2012/studio

Programme committee chairman Professor Michael Böhm: “the scientific excellence of our meeting now attracts a truly global audience.”

09:30 RoomTbilisi-CentralVillageTelehealth: for whom, when and how?

11:00 RoomTbilisi-CentralVillageHeart disease in women: an update

14:00 RoomTbilisi-CentralVillageHow can we improve cardiovascular prevention?

15:15 RoomTbilisi-CentralVillageCardiovascular nursing in Germany: present and future

17:00 RoomMunich-CentralVillageOpening Ceremony

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the spotlight of this year’s event is “From bench to practice”, which aims to facilitate the rapid transfer of novel techniques into clinical practice. “our theme is in recognition of the fact that it’s only through concerted efforts that we can hope to make further improvements in patient care,” says Michael Böhm. sessions, he adds, will focus on both research achievements that have already been transferred into clinical practice

and on potential opportunities for the future. over 14 sessions will cover topics including cardiac resynchronisation, micro-RnAs as therapeutic targets, stem cells for cardiac repair, remote ischemic conditioning and modulation of the sympathetic nervous system. “we hope these sessions will benefit both young and established cardiologists by helping them to understand more about the translational process,” says Böhm.

Spotlight of this year’s congress

2

The insider’s guide to Munich

Suggestions beyond the ESC Congress

HEARt sPECIALIsts are traditionally very welcome in Munich and throughout Bavaria. outside the EsC Congress, there is much for them to enjoy. A good start is a walk through the old town, starting at the town Hall at Marienplatz, and from there a few minutes’ stroll to the famous Viktualienmarkt. what used to be just another farmers’ market has now turned into an essential source for the city’s gourmets.

open every day except sunday and into the evening, the market has more than 100 stalls, selling everything from flowers to exotic fruit, wild game, poultry and fish, spices, cheese, wine and beer. If you’re in the mood for just relaxing after a long congress day with some light sightseeing, the 500-acre nymphenburger schlosspark is outstanding, with splendid gardens and lakes, endless trails, meadows and quiet corners. the park surrounds the late 17th/early 18th century summer residence of Bavaria’s kings. the baroque palace houses several outstanding collections and exhibits. Ready for a shopping tour? the grand Maximilianstrasse boulevard is lined with elegant designer boutiques - and by the way, it is in this same area - at the wittelsbacher Platz - where the public

event presented by the German Cardiac society and the German Cardiac Foundation takes place (see below). or walk through the pedestrian zone from the stachus (Karlsplatz) to the Marienplatz, or from the theatinerstrasse to the odeonsplatz past the Fünf Höfe shopping centre to the imposing theatinerkirche st Kajetan. Art-lovers should not miss Munich’s museums, all within walking distance: the Kunstareal Munich, Barer straße, has something for all tastes. You might also enjoy the current Marcel Duchamp - Mystère de Munich exhibition, which marks the centenary of the artist’s three-month stay in Munich in 1912. this is at the Pinakothek der Moderne, which houses 20th and 21st century work from Matisse to Dali and warhol, and is one of three remarkable museums in the area. the others are the Alte Pinakothek (stefan Lochner, Albrecht Dürer, Rembrandt, Leonardo da Vinci), and the neue Pinakothek (18-19th century, including Renoir, Monet, Cézanne, Gaugin, van Gogh and

Picasso). off the beaten track, the renovated Valentin Karlstadt MUsÄUM at the Isartor celebrates the Bavarian comedians Karl Valentin and Liesl Karlstadt. those interested in science and technology should head for the Deutsche Museum situated on a former sandbank in the Isar river (Museumsinsel 1). It is full of superlatives: the wright brothers’ first motorised

aircraft, the U1, the first German naval submarine, and the Z3, the first fully operational electromechanical computer built by the inventor Konrad Zuse in 1941. Munich may be about as sophisticated as it gets but it’s still famously famous for its beer and “Laugenbrezn”, white sausages and “Leberkäs”. try the beer garden at the Chinese tower in the 900-acre English Garden, or what is the largest beer garden in Europe, with 8000 seats within a two-acre deer-park, at Hirschgarten 1. If the weather is unkind, Bavarian specialties can also be enjoyed at the Hofbräuhaus, founded in 1589 (Platzl 9), the Augustiner am Dom (Frauenplatz 8), or the Ratskeller München (Marienplatz 8).

“Everything for the heart” is the theme on wittelsbacher Platz on 24/25 August when the German Cardiac society and German Heart Foundation stage a public information event to coincide with EsC Congress 2012. Experts will be on hand to offer a journey of discovery through the maze of modern cardiology. they will explain how a defibrillator can save lives and how cardiac ultrasound, MRI, and Ct imaging work. Leading

experts will give practical advice and explain why regular heart checks are as important for sporting types as they are for those who no longer exercise, and what the key risk factors are. there will also be free health checks for blood pressure, blood sugar and cholesterol, BMI and other assessments of cardiac risks. And of great importance to the people of Munich, a celebrity chef will help demonstrate preventive measures

with heart healthy food, with delicious samples to taste. And to keep things moving sports fans as well as couch potatoes will be invited to take part in relaxed warm-up exercises, or to train with the ladies of the German national ice-hockey team, or score their own goals on a goal-wall. there will also be fitness presentations or demonstrations of the best way of organising exercises without too much strain on the heart.

www.escardio.org

. . . and healthy hearts for everyone

By Eckart FleckDirector German Heart Institute

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Marienplatz

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Five new practice guidelines are lined up for presentation at ESC Congress 2012

By Jeroen J BaxProfessor of CardiologyLeiden University Medical Center the netherlands

FIVE nEw guidelines and one consensus document have been completed over the past year, and all will be presented during EsC Congress 2012.

Cardiovascular disease prevention is a joint document developed by the EsC and eight other specialty societies. It is a new approach on CVD prevention and answers the five key questions of prevention: what is it, why is it needed, for whom and by whom, and how it can be provided? the new guidelines provide an update of our present knowledge in preventive cardiology but differ from the 2007 edition by a greater focus on new scientific knowledge and by the use of grading systems, so allowing more evidence-based recommendations to be adapted to the needs of everyday practice.

Heart failure (including acute and chronic) is a new version of the practical, evidence-based EsC Guidelines of 2008, 2005, 2001, 1997 and 1995. this new version provides therapeutic recommendations with treatment effect supported by the class and level of recommendation in tabular format. Detailed summaries of the key evidence supporting generally recommended treatments have been provided, as well as practical guidance for the use of the more important disease-modifying drugs and devices.

Valvular heart disease was written jointly by the EsC and European Association for Cardio-thoracic surgery (EACts). the previous version was published in 2007 and was written solely by the EsC. this is the first time the two societies have joined forces to develop guidelines on valve diseases, which now provide a critical evaluation of diagnostic and therapeutic procedures including assessment of the risk-benefit-ratio. Estimates of expected health outcomes for larger populations were also included, where data exist.

The 2012 AMI-STEMI guidelines are a very practical update to the 2008 version. they shed light on the great number of trials of new treatments performed in recent years as well as on new diagnostic tests. Because of major developments in the biomarkers available for diagnosis, the criteria for acute myocardial infarction have been revised. the present guidelines apply to patients presenting with ischaemic symptoms and persistent st-segment elevation on the electrocardiogram (ECG). A Focused Update of the 2010 ESC Atrial Fibrillation guidelines has also been produced for 2012. the update was considered necessary because of the fast pace of clinical outcomes research in AF, and considerably more

clinical experience in the fields of anticoagulation, anti-arrhythmic drugs, atrial appendage occlusion and ablation procedures.

The Universal Definition of Myocardial Infarction provides an update of the joint EsC/ACCF/AHA/wHF document published in 2007. the third task Force on the subject has continued the joint efforts by integrating new insights and data into the current document, which now recognises that very small amounts of myocardial injury or necrosis can be detected by biochemical markers and/or imaging.

the six task Forces and their respective chairs are to be congratulated for their extensive efforts! All six 2012 EsC documents provide an excellent summary of the latest information on the different topics and will provide an invaluable resource for all professionals involved in the care of patients with cardiovascular disease. In addition, gratitude should be expressed to the EsC guidelines team, headed by Veronica Dean, for the superb support during the year to enable the production of these six documents. All six guidelines will be presented in an overview session tomorrow morning, followed by specific and more detailed sessions on all titles over the next three days.

there will also be three sessions of Meet the Guidelines task Force on sunday afternoon and tuesday morning, where all six documents will be presented and discussed in an informal way with the teams involved in their development.

26 August 08:30-10:00Munich, Central Village2012 EsC Guidelines overview

www.escardio.org

www.escardio.org

4

Linking blood flow and cardioprotectionA scientific exploration in tomorrow’s William Harvey lectureoRIGInALLY Gerd Heusch, who delivers this year’s EsC william Harvey lecture on basic science, had wanted to study classics, but his plans changed after he attended a series of physiology lectures at the University of Bonn. “I was impressed by the fact that the functions of the body, including the circulation, could be explained in such a logical and rational way,” recalls Heusch, now chair of the Institute of Pathophysiology at the University of Essen Medical school, Germany. “the whole approach didn’t feel that different from Latin and Greek, except it had far more useful applications.” Ever since, Heusch, who graduated in medicine in 1979, has been putting his physiological knowledge to good use. Much of his career has focused on basic science, challenging the paradigm that ischaemia was “a maximum vasodilator” stimulus, and helping develop the concepts of “perfusion-contraction matching” and “hibernating myocardium”. In tomorrow’s lecture he will explore his most recent research enthusiasm, cardioprotection. Cardioprotection, explains Heusch, is any intervention which prevents or attenuates myocardial infarction (MI). one focus of investigations has been the conditioning phenomenon in which briefly interrupted blood flow just prior to or following a MI can in some way boost heart muscle survival. In animal and more recently in clinical proof-of-concept studies it has been shown that infarct size is reduced by brief interruptions to the coronary circulation (by coronary artery ligatures) both before (known as preconditioning) and after the infarct (post-conditioning). An even greater curiosity is the phenomenon of remote conditioning, where occluding arteries in the limbs just prior to the MI delivers similar beneficial effects. such ease of access offers the potential for practical applications. Indeed, an innovative study by Hans Erik Bǿtker from Denmark has shown that in patients with suspected MI repeated blood pressure cuff inflations during ambulance transfers to the hospital improved myocardial salvage (Lancet 2010, 375: 727-34). More recently Heusch has shown that patients receiving remote conditioning with blood pressure cuff inflations just prior to CABG had a 50% reduction in troponin levels, used as a marker of cardiac damage (Circ Res 2012, 110:111-15).

Heusch’s attention is now focused on explaining the signal transduction pathways involved (ie, the chemical messengers translating signals from outside the cell into function changes within the cell). “the ultimate convergence point for these signals we believe to be the mitochondria, where the efficiency of energy delivery is improved and production of reactive oxygen species reduced,” says Heusch. Front runners for molecules thought to play a role in the pathway include adenosine, bradykinin, and the signal transducer and activator of transcription protein (stAt), which has more recently been identified as a central element, located close to the mitochondria. In biopsies taken directly from the hearts of patients who had had blood pressure cuff inflations just before CABG, Heusch showed raised activation of stAt5. “we’re optimistic that if we can identify the signalling steps involved in cardiac protection we’ll ultimately be able to create therapies that enhance them,” he says. outlining the challenges, he explains that one of the major obstacles is that animal models can be a long way from the

human situation. “Inevitably animals tend to be young, don’t have co-morbidities and haven’t been exposed to a range of drug treatments,” says Heusch. there are signs, he adds, that signalling may be affected by co-morbidities, such as diabetes, and medications. while Heusch has spent much of his career focused on basic science, he has been mindful to step out of his ivory tower. “Academic work can be really esoteric. I’ve recognised that to bring about any change for the better science should be combined with politics,” he says. Heusch can be justifiably proud of his term as president of the German Cardiac society (2007-2009), where he instigated two initiatives with a lasting effect on both CVD research and practice in Germany. First, he initiated the idea of the German Centre for Cardiovascular Research, a virtual centre that allows seven sites in Germany to share facilities and develop a strategic joint strategy for research. the centre was launched in May 2012. second, he promoted the development of an accreditation process for chest pain units in Germany. the scheme, run by the German Cardiac society, expects centres to meet defined standards for equipment, diagnostic and therapeutic strategies, staff education, and for cath labs available 24 hours a day for 365 days per year. one problem Heusch feels he has not yet resolved is the falling numbers of clinicians involved in translational research. this, he believes, has much to do with pay disparities between young cardiologists entering basic research and those doing clinical work. “the current financial crisis has made it difficult to persuade the government to provide additional funding for clinician scientists. All we can do is to try and attract people by the quality, enthusiasm and excitement of good research,” he says. Hobbies for Heusch, who is married and has three adult children, include reading around ancient history and running 30 to 40 kilometres a week. “while prevention is a motivation, the monotony of jogging helps me to turn off from work more than anything else,” he says. JF

26 August 11:00-11:45 - Tbilisi, Central VillageEsC william Harvey Lecture on Basic science

Gerd Heusch: one focus of investigations has been the conditioning phenomenon in which briefly interrupted blood flow just prior to or

following a MI can in some way boost heart muscle survival.

EHJ continues its record gains in impact factorHAVInG BRoKEn through into the exalted realm of double-digit impact factors last year, the European Heart Journal has continued its “steady progress”, now with a further impact factor rise to 10.478 for 2011 citations. “If we can continue with a half-point increase each year,” says editor-in-chief thomas Lüscher, “we’re well on our way to an impact factor of 11 for 2012.” this, he adds, will put the EHJ within reach of its two publication rivals, Circulation (at 14.739) and JACC (at 14.156). while impact factors may still be controversial in some corners of science and clinical research, in academic publishing they remain the clearest statement yet of journal quality. this is why the EsC and its journal publishers had such huge cause for celebration last year when the IsI web of Knowledge announced its impact factors for 2010 and the EHJ’s move into double digits. this drive to improve the journal’s quality is not just evident in original research articles, but in its full editorial spread, which has seen substantial recent efforts in the range and quality of invited content. “we’ve been extending our news coverage with CardioPulse,” says Lüscher, “and publishing more guidelines, editorials and commentaries. we think these can be extended even further.”

More invited manuscripts is one important strategy for next year, when, in January 2013, the EHJ will become a weekly publication. “It will bring us in line with JACC and Circulation, which are both weekly,” explains Lüscher, “and give us a better reading rhythm. the psychology of reading is changing, and we have to change with it.” “It’s also quite clear now that the journal is not just about original research, but also about influence and education,” he adds. to illustrate, Lüscher cites the instance of the EsC’s 2009 guidelines on infective endocarditis, which since publication in the EHJ have generated 119 citations but a remarkable 48,000 downloads. “It’s a typical example of how the journal is moving,” says Lüscher. “Here is use by physicians in practice for their own education and resources. It’s not just about impact factor but about the influence the journal is having on the everyday life of physicians.” such a huge number of downloaded papers also reflects the publishing drift of medical journals - away from the print-only concept of just a few years ago to one which, eventually, will be electronic only. “It’s not a question of if, but when,” says Lüscher, “but it will happen, probably within the next ten years. Already, we’re well aware that

our younger subscribers are online users only, and we’ll see this even more here in Munich when subscribers choose paper or electronic.” with weekly publication the business model of paper publishing - with print and distribution costs - also becomes increasingly challenging. Electronic publication will make the finances of weekly publication more manageable. However, Lüscher does not expect weekly publication to dilute the quality of the journal, or increase the acceptance rate, which remains at around 10%. “we have been seeing a steady increase in manuscript submissions,” he says, “which this year will rise to around 3700. we anticipate that the growing impact factor

and weekly publication will make the journal eve more attractive and continue the trend. It is already a very high rejection rate, which makes more people unhappy than happy with the outcome, but our main aim has to be manuscript quality.” to soften the blow of rejection, the EHJ recently introduced a scheme for transferring good quality rejected papers to appropriate sister titles in the EsC journal family, and this, says Lüscher, is already seeing huge benefits. More than 500 manuscripts have so far been transferred to other EsC titles, from which both the authors (75 papers published so far) and the journals have derived benefit. the European Journal of Heart Failure, for example, increased its impact factor to 4.896 in June, now ranking it in the top twenty of world cardiology journals. there are presently eight titles within the EsC journal group, the latest - Acute Cardiovascular Care - introduced at the start of this year with a strong educational focus. sB

26 August 08:30-10:00 Tbilisi, Central VillageImpact factors and electronicjournals: publishing at the speed of light

EHJ editor-in-chief thomas Lüscher: “It’s quite clear now that the journal is not just about original research, but also about influence and education.”

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Tele-health ‘feasible’ for primary careScientific SeSSionS on a Saturday - even before the opening ceremony - are an emerging eSc congress trend, which began in 2010 with a day-long session specifically designed for primary care physicians. there are 49 sessions (including poster sessions) in today’s scientific programme, and continuing from last year one on “general cardiology” for family physicians and nurses. the first symposium of the programme features one field of cardiology where primary care involvement is feasible and where that involvement may have real patient benefits - in telemonitoring and telehealth. Remote telemedical management is emerging as an intervention which may help improve therapy in both heart failure and hypertension. However, in heart failure the benefits of telemonitoring appear rather conflicting, which may well have left many family physicians unsure about its role. first, a cochrane review from 2010 found that both telemonitoring and structured telephone support appeared significantly effective in reducing mortality and rehospitalisation in chronic heart failure patients. Both interventions improved quality of life, reduced costs, and were acceptable to patients with improvements in prescribing, patient-knowledge and self-care, and functional class. However, the tiM-Hf trial (which used mobile phone technology to transmit data from homecare ecG and blood pressure monitoring) reported last year found benefits only in clearly defined sub-sets of heart failure patients but no clear overall benefits. Similarly, heart failure patients taking part in the 2010 tele-Hf multicentre trial (structured telephone support using a phone-based interactive voice response system) found no advantage of telemonitoring-

guided management over the usual care. John cleland, who will review telemonitoring in heart failure this morning, described the results of both trials as “disappointing”, but told Congress News that it clearly matters how any system is designed and applied. “it matters how you do it,” he said, adding that “practical experience” will probably be more valuable than clinical trials. Less controversial are the benefits of telemonitoring in hypertension, in which even the simple discipline of daily self-monitoring has been shown by systematic review to improve systolic BP by around 2-3 mmHg. indeed, said oxford investigator Richard McManus, a large proportion

of hypertensive patients already monitor their own blood pressure, so “telemonitoring” would simply extend that exercise and quickly pass on the results to the primary care physician. “telemonitoring allows us to have a two-way communication without multiple clinic visits,” explained McManus, adding that communication might be by way of an internet site or by mobile phone text, with some form of automated response usually common to all systems. the objective, he said, is not just greater cost efficiency, but emphatically improved blood pressure control. With as many as 50% of hypertensives failing to meet their BP targets, the population benefits are likely to be substantial. A randomised trial of telemonitoring and BP self-management performed by McManus and colleagues in 24 UK general practices found that systolic BP decreased by 5.5 mmHg more in the intervention group than in the control group after 12 months. “But you can’t just have telemonitoring on its own,” he warned. “You need to be able to do something about it.” Some systems, he explained, operate on a traffic-light system whereby raised readings prompt a response from a doctor or nurse, a visit to the clinic or even a self-adjusted increase in drug dose. “So telemonitoring is effective provided that a management system is in place to act upon it,” said McManus, who emphasised that telemonitoring and self-management are especially suited to primary care. SB

25 August 09:30-10:30 - Tbilisi, Central Villagetelehealth: for whom, when and how?

5

Richard McManus: even daily self-monitoring improves BP control.

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• evidence showing the benefits of prolonging dual antiplatelet therapy beyond one month was generated in the BMS era in the cURe and cReDo studies context. that evidence is, however, questionable, given that patients treated with clopidogrel beyond one month were receiving earlier treatment than those who had received one-month clopidogrel only. therefore, the possibility that clopidogrel pre-treatment biased the effect of post-treatment is of real concern. only the cHARiSMA study tested the effect of long-term clopidogrel therapy without the “pre-treatment bias” and it failed to show that long-term clopidogrel is better than aspirin alone. • three randomised controlled studies have so far tested two different dual antiplatelet therapy durations in the context of first or first and second generation DeS. they failed to show that longer duration is

better. in the PRoDiGY trial the 24-month duration of clopidogrel, as opposed to six months dual antiplatelet therapy, more than doubled the risk of clinically meaningful bleeding events and the need for red blood cell transfusions. • A meta-analysis of these three studies has been performed which showed that long-term therapy (12 months or more) increased overall tiMi-defined major bleedings as well as the overall risk of cerebrovascular accident, with no discernible benefit in any of the investigated ischaemic endpoints, including any death, cardiovascular death, reinfarction, or stent thrombosis. • the PRoDiGY and eXceLLent studies provide reassuring data showing that six months dual antiplatelet therapy is no better than the longer duration with respect to the tested newer generation DeS, including Xience and endeavor Sprint stents.

• finally, registry data on antiplatelet duration and outcomes are difficult to interpret, as they almost systematically fail to consider the reason for discontinuation of therapy, which includes surgery and bleeding events. these adverse events in themselves carry prognostic implications and may explain some of the findings so far.

in conclusion, planned on-going studies will increase our knowledge and hopefully conclusively ascertain the true, unbiased value of dual antiplatelet therapy after stenting. Meanwhile, we should implement the best available evidence - and today’s evidence clearly vouches for six-month therapy duration as the most reasonable choice after the implantation of newer generation DeS stents.

YES, says Marco ValgimigliUniversity Hospital of ferrara, italy

www.escardio.org

Debate: Is six months dual antiplatelet therapy sufficient after DES placement?

formal debates may be useful to put hot topics into perspective but invariably they lack the e v e r y d a y practicality to be useful to the

physician. thus, in my consideration of limitations to the use of antiplatelet therapy for up to six months after drug eluting stents (DeS), i will express arguments in two contexts - the historical and the patho-physiological - in order to provide a more patient-oriented opinion which is relevant to daily practice. But first, in consideration of the debate’s title, it will be assumed that when we are speaking about “antiplatelet therapy” in the context of DeS, we emphatically mean dual antiplatelet therapy - that is, the combination of acetylsalicylic acid (eg, aspirin) and a P2Y12 receptor blocker (eg, ticlopidine, clopidogrel). So first, the historical context. four randomised trials (intracoronary Stenting and Antithrombotic Regimen [iSAR], full Anticoagulation Versus Aspirin and ticlopidine After Stent implantation [fAntAStic], Stent Anticoagulation Restenosis Study [StARS], and Multicenter Aspirin and ticlopidine trial after intracoronary Stenting [MAttiS]) have demonstrated the superiority of dual antiplatelet therapy over the combination of full-dose anticoagulation and aspirin to prevent thrombotic events after bare metal stent (BMS) use. in the BMS era, dual antiplatelet therapy after stenting was maintained for four weeks. in some cases it could even

been shortened to 7-10 days if necessary. the development of brachytherapy, a potent anti-restenotic therapy, and its combination with stenting revealed an increment in the incidence of late stent thrombosis. Data from registries (Scripps coronary Radiation to inhibit Proliferation Post-Stenting [ScRiPPS]-iii and Washington Radiation for in-stent restenosis trial [WRiSt]-Plus) and from randomised trials (BetA-cAtH System trial) showed that late stent thrombosis rates were lower when dual antiplatelet therapy was extended to 6-12 months. Against this background it is clear that the debate on the duration of dual antiplatelet therapy is nothing new but it has nevertheless become a topic of intense debate in the DeS era. Yet in the literature data concerning the optimal duration of antiplatelet therapy after DeS are scarce, and inadequately powered and designed to allow an evidence-based answer. this is also reflected in the 2010 european guidelines on myocardial revascularisation, which contain only a few educated suggestions on the duration of dual antiplatelet therapy after DeS, some of which to me appear contradictory. therefore the most reasonable approach - which is independent of the information given in the literature or guidelines and independent of the current debate about the optimal duration of antiplatelet therapy - begins with an understanding of why antiplatelet therapy has (re)emerged as an important topic of discussion. the problem has been the risk of late stent thrombosis. it is now well established that the single most relevant factor influencing the rate of late stent

thrombosis after DeS insertion was the prolongation and interruption of dual antiplatelet therapy respectively. thus, an understanding of the patho-physiological mechanisms triggering in-DeS thrombosis appears one of the key factors in how the duration of antiplatelet therapy should be modulated. According to histo-pathological post-mortem analysis as well as following in vivo intracoronary optical coherence tomography (oct) evaluations, it seems that the pro-inflammatory and healing characteristics of DeS differ from those of the BMS. Potent DeS are associated with delayed healing pattern and persistent risk of late/very late stent thrombosis. furthermore, various types of DeS have different healing patterns and thus different clinical risk profiles. thus, there is no class-effect of DeS, and every DeS system has its own characteristics - so the patient should be made aware of the DeS type that has been implanted. Also of clinical relevance to the individual patient is the determination of his/her net clinical benefit. this can be seen as a trade-off first between the strong prevention of revascularisation with a potent DeS and an increase in the long-term pro-thrombotic risk, and second, strong thrombotic protection from prolonged dual antiplatelet therapy at the cost of an increased risk of bleeding. therefore, guidance on the duration of antiplatelet therapy after DeS will depend mainly on two factors: first, the type of DeS selected; and second, the hemorrhagic risk to the patient. And it’s for these reasons that the duration of antiplatelet therapy will always have to be determined on an individual patient basis.

6

26 August 08:30-10:00 - Prague, Village 4 - controversies in antiplatelet therapy

No, says Edoardo CamenzindUniversity of Geneva, Switzerland

i have lost count of how many times colleagues and even patients have asked me if i was really sure that clopidogrel could be stopped so early (that is, after only

a few months of dual antiplatelet therapy, despite a previously implanted DeS). the concept of “the longer the better” dominates our thinking and, without any evidence, this message is neither resisted or challenged. So it’s time to re-interpret the evidence with scientific rigour - and not an emotional reaction. We have been told that drug-eluting stent (DeS) implantation may increase mortality. the reason would be the occurrence of late and very late stent thrombosis, and the cure would be to leave our DeS patients in a long-term regimen of dual antiplatelet therapy, ideally indefinitely. indeed, guidelines are providing the minimally reasonable duration (ie, up to 12 months) but they fail to tell us the upper limit of therapy duration - again implying that the “longer the better” concept is valid. is this true? So let’s look at the facts.• DeS do not increase mortality. there is no randomised study or meta-analysis showing an excess of fatal events after DeS over bare-metal stent (BMS) implantation, nor even one showing that the incidence of late stent thrombosis is greater with DeS than BMS. • However, there is evidence that the rate of very late stent thrombosis is higher after cypher or taxus stent implantation. this excess of very late (ie, after 12 months) events is, however, offset by a lower risk of such events within the first year after implantation, which explains why any patient- or stent-based endpoint has no overall higher rate after DeS than after BMS. • the cypher stent has been withdrawn from the market - and this is almost so for taxus. taxus remains available but its use is negligible across europe.• Accumulating data show that the risk of very late stent thrombosis with many second generation DeS, including Xience, endeavor Sprint and Biomatrix flex, is not increased when compared with BMS, or is significantly lower when compared with cypher or taxus. Recent studies show that the rate of overall stent thrombosis is significantly lower with these newer generations DeS when compared with BMS. this no doubt reflects the fact that the drug-eluting in itself or some polymers may actually reduce the risk of acute, sub-acute and late thrombosis, whereas the absence of long-term stent toxicity avoids very late thrombotic events and make these newer generation DeS at least as safe beyond one year as BMS.

Leading the RE-VOLUTION®

RE-VOLUTION® is a clinical trial programme in thromboembolic diseases by Boehringer Ingelheim

You be the judge

Monday 27 August 2012 18:30–20:00, Algiers – Village 2, Messe München

A satellite symposium held during ESC Congress 2012 25–29 August, Munich, Germany

Invitation

Stroke prevention in patients with atrial fibrillation – different perspectives and practical approaches

Co-Chairs: Professor Michael Böhm Professor Gregory Lip

18:30 Setting a new course: Michael Böhm welcome and introduction Germany

18:40 Navigating a changing landscape: what Gregory Lip

factors should we consider when choosing UK

an anticoagulant for stroke prevention? Matthias Endres Germany

19:10 Choosing the right path: what is the Stuart Connolly

evidence supporting dabigatran Canada

etexilate and how can we optimize Paul Dorian

use in clinical practice? Canada

19:40 Let our audience lead the way: Moderated by Gregory Lip panel discussion UK

19:55 Moving forward together: Gregory Lip summary and close UK

Programme

www.escardio.org

7

Young cardiologists now take the stagethe clinical case corner, now in its second year, will give 42 young cardiologists the chance to present challenging cases to an international audience. the six separate sessions, taking place on Monday and tuesday (village 10), have been specially selected by a group of nine young cardiologists to provoke discussion. Particularly noteworthy for this year is the “revolving stage set-up” designed to facilitate maximum audience participation and interactivity. the initiative, developed by eSc cardiologists of tomorrow, invited cardiologists under 36 to submit clinical cases on two themes for consideration - systemic diseases and emergencies in cardiology. Altogether 365 clinical cases were submitted, all of which were graded “blind” by a panel of young cardiologists recruited from across europe. “Participation in grading gives young cardiologists opportunities to learn about how abstracts get selected,” says Ricardo fontes carvalho, the cardiologist in training from Portugal responsible for co-ordinating the event. once the average scores had been calculated, the four top scoring cases were identified and scheduled for presentation in the challenging case Reports Session. At this session a panel of six young cardiologists will judge the overall winner, who will be awarded a prize of €2000, with each of the three runners up receiving €1000. the next 42 highest scoring cases have been identified and will be shown in the clinical case corner, with submissions on Sunday grouped into themes. each of the six sessions will be moderated by a cardiologist of international stature and a cardiologist in training. the room design, with revolving stage, is intended to maximise interactivity. “the idea is to allow moderators and speakers to face every section of the room for at least a few minutes of each session,” says fontes carvalho. often the featured cases are not straightforward. “We purposefully identified cases where there were several treatment options requiring clinical judgements to be

made,” says Stéphane Zuily, a young cardiologist from france who took part in the case selection. one noteworthy presentation, by Jaume francisco Pascual, from University Hospital Vall d’Hebron in Barcelona, provided the example of a 47-year-old man found at autopsy to have suffered from the genetic condition fabry’s disease following his death from cardiac arrest. the finding enabled family members to be screened and treated with recombinant alfa-galactosidase. “this case really illustrated

the importance of being alert to strange manifestations of cardiac disease,” says Zuily. All the accepted cases will be published in the abstract supplement of the European Heart Journal in August.

ESC Cardiologists of Tomorrowthe eSc cardiologists of tomorrow initiative, launched in 2010 at the eSc congress in Stockholm, is dedicated to supporting young cardiologists in training across europe. the organisation provides educational activities, training and research grants, and plenty of opportunities for networking to facilitate professional development. “our idea was to encourage young people to become engaged with both their national cardiac societies and the eSc,” says Steen Dalby Kristensen, who developed the initiative during his term as eSc Vice President. “there’s a continual need to recruit clinicians and scientists willing to volunteer their time to eSc activities, and to ensure that future leaders of the eSc are coming through.” eSc cardiologists of tomorrow is co-ordinated by a nucleus of seven young cardiologists from seven different countries, with specific areas of responsibility. elections are currently under way for new members. the initiative awards a number of different grants, with training awards available for those who wish to update their clinical training with modern cardiology methods, especially when it is impossible to learn particular techniques in their own countries, and research grants

for both medical and science graduates. eSc cardiologists of tomorrow also has an important role to play in helping national cardiac societies set up their own young cardiologists groups. Altogether 25 national groups for young cardiologists have now been created in europe. events at eSc congress 2012 on the cardiologists of tomorrow track (Monday, 08:30-18:00, tbilisi, central village) feature scientific sessions of special interest to the younger generation. themes include looking at new technologies, tAVi development, pocket echocardiography and a practical “how to” session explaining the tips and tricks of clinical trial interpretation. in addition, 25 young cardiologists from each of the national cardiac societies have been selected for free registration at the Munich congress. Jf

27 August 14:00-15:30 - Tbilisi, Central Villagechallenging case Reports from the eSc cardiologists of tomorrow: emergencies in cardiology and cardiac involvement in systemic diseases

ESC CARDIOLOGISTSO F T O M O R R O W

cardiologists of tomorrow nucleus members enjoying eSc congress 2011 in Paris.

faces in the crowd

Saturday 25 August 2012 14:45–16:15

Room Zagreb, Village 2

Messe München

A Daiichi Sankyo Europe GmbH and Eli Lilly and Company sponsored satellite symposium

MODERN INHIBITION OF PLATELET AGGREGATION: Experience and future outlook

4-000132

What are you looking forward to at ESC Congress 2012?

Andreas SchoenenbergerResearch leader and head physicianBern, Switzerland

Sabine PankuweitSenior researcher Marburg, Germany

tomoya HoshiUniversity of tsukubatsukuba, Japan

catherine Szymanskiclinic DirectorDouai, france

faces in the crowd

editors-in-chief:Michel Bertrand, Stephan WindeckerMedical writers: Janet fricker, Sophie Goodchild

Sub-editor: Simon Brown Graphic Design: Hobby one Multimedia

Printing company: G. Peschke Druckerei GmbHPhotography: Patrik engström

Sponsorship: sponsorship@escardio.org Project Management: Alexandra Gamard, agamard@escardio.org

With the support of the eSc congress 2012 Press committee. free distribution. copyright eSc 2012

eSc conGReSS neWSMunich, Germany25 - 29 August 2012

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it is a great honour to be a part of the eSc congress, which i know is considered the most important event in the field. i am attending to improve my knowledge and take part in scientific exchanges and debates. Live sessions, especially those based on cardiac surgery or percutaneous techniques, are very exciting - and the sessions on the latest clinical trials have a direct application in our practice. finally, we can meet people from all over the world: fellows, senior cardiologists involved in innovative projects, and the cardiologists of tomorrow, the initiative for young doctors to present their own original work.

As a clinical scientist i look forward to this year’s eSc congress with high interest, as the spotlight, translating innovative science into daily clinical practice, is one of the major goals of our daily work. translational research should be encouraged in the upcoming years especially in the field of heart failure. During the five days of congress - with scientific sessions arranged by topics in themed villages for more convenience - i look forward to having the opportunity for education at a high level, the possibility of discussion about research results and meeting collaborators and colleagues from around the world.

cardiovascular disease has been largely responsible for morbidity and mortality around the world. it is strongly associated with lifestyle, especially unhealthy diet, physical inactivity, obesity, and cigarette smoking. What is the optimal tool for estimating the high risk population for cVD? What is the most effective intervention to reduce the burden of cVD, as well as estimating cost-effectiveness? Healthcare professionals should create an environment supportive of lifestyle modification, risk factor treatment, and drug intervention. i look forward to discussing ways to address these challenges with the goal of reducing the burden of cVD.

i am most looking forward to the exchange of information. As a researcher, i look forward to discussing new findings with other investigators. As a geriatrician, i expect to meet interesting cardiologists and to see the new developments in the field. i am most interested in the new eSc clinical Practice Guidelines on SteMi, valvular heart disease and heart failure, which are, because of their prevalence, diseases of the older patient. finally, as a human being, i will enjoy having a good Bavarian beer together with friends. So, let’s meet together! My field of practice - it’s geriatrics, and in particular geriatric issues in cardiology.