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Conference Update

Cardiology, October 2007

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 the prevention of cardiovascular disease and management of hypertension

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

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 had died No evidence of increased mortality in NSTEMI Limitations:
No info on the type of DES or BMS use Characteristics of lesions: length, calcification or bifurcation

Bioabsorable stents: the next frontier?

Enormous potential Stent disappears after initial healing Removes problem of late stent thrombosis and need for long term anticoagulation Advantages:Dont show up on CT/MRI Cardiothoracic surgeons:metalfree segment if reintervention needed 2 types: polymer and metal based

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 of stented segment of the vessel

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

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

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

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 response triggered Further studies needed: a) time to normalisation of levels b)what impact it has on heart and endothelial function

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 (<50 years) and women

Diabetes: prevalence from 17%-28% Hypertension: no. of pts reaching target BP from 41% to 39% Large in prescriptions of antihypertensives Lipids: management much improved Need for preventive cardiology programmes Professional intervention by MDT for lifestyle change <1/3 of pts have access to structured preventive and rehabilitative programmes

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

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%

Percutaneous Transfemoral Retrograde Approach

214 Pts > 70 yrs Valve area <0.6cm2 NYHA II or more At very high risk Success rate >85% 30 day mortality 10-12% MI rate 1% Limitations: difficulty using large sized valve because of arterial conditions

No place for supplements as secondary prevention in CAD

Vitamin B supplements not justified as secondary prevention in CVD Western Norway B-vitamin intervention trial (WENBIT) 3090 pts with CAD Placebo, vit. B6, folic acid plus vit. B12 and combination of 3. Homocysteine levels by 28% in group receiving folate No protective effects found

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)

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

163 patients

89 Previously diagnosed AFib 44 on adequate antithrombotic therapy

77 diagnosed on admission

On discharge 15% with known Afib were undertreated according to the guidelines Estimated that 25 of 89 cases could have been prevented but 5 more cases of intracranial haemorrhage To improve the situation CHADS2 score needs to be calculated

Stem Cells: a paracrine effect in Heart Failure?

Use of stem cells to improve cardiac function in heart failure Paracrine effects a)induction of angiogenesis
b)inhibition of apoptosis c)protection from ischaemic induced injury

Most research done in MI Complications with stem cells in HF: established scars and diminished homing capabilities Promising results in recent studies (TOPCARE-CHF)

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 of stem cells are produced by paracrine mechanisms rather than proliferating cells that generate a new myocardium Future?? Need to improve cell delivery, isolation and storage Current study: penetrating the heart with US guided low energy shock waves cytokine levels homing capacity

Guidelines for the Prevention of Cardiovascular Disease

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 with end organ damage

Close relatives of subjects with premature atherosclerotic CVD or those at high risk

Objectives of CVD prevention

Primary prevention
No smoking Healthy food choices Activity: 30mins mod exercise/day BMI<25 kg/m2 Total cholesterol <5mmol/l LDL cholesterol <3mmol/l Blood glucose <6mmol/l

3) To achieve more rigorous risk factor control in high risk pts (established CVD or diabetes)

BP <130/80mmHg Total cholesterol <4.5mmol/l with option of 4mmol/l if feasible LDL cholesterol <2.5mm/l with option of <2mmol/l if feasible Fasting blood glucose <6mmol/l and HbA1c < 6.5%

4) To consider cardioprotective drug therapy in high risk pts

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, total risk can be by reducing other risk factors Aspirin recommended for all pts with established CVD and in persons >10% SCORE risk once BP controlled

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 pts regardless of baseline levels

SCORE risk >5%

Lifestyle advice 3 months Reassess SCORE and lipids >5% statins recommended TC<5,LDL-C<3 and SCORE <5% regular follow up

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Antihypertensive treatment:preferred drugs

Previous Stroke Previous MI Any BB, ACEI, ARB

Angina pectoris
Heart failure

Diuretics, BB, ACEI, ARB, antialdosterone agents ARB, ACE BB, non-dihydropiridine CA ACEI, ARB, loop diuretics CA

Atrial fibrillation Recurrent Permanent

ESRD/proteinuria Peripheral artery disease

Subclinical Organ Damage

LVH Asympt. atherosclerosis Microalbuminuria Renal dysfunction ACEI, CA, ARB CA, ACEI ACEI, ARB ACEI, ARB

ISH (elderly) Metabolic syndrome Diabetes Mellitus Pregnancy Blacks Diuretics, CA ACEI, ARB, CA ACEI, ARB CA, methyldopa, BB Diuretics, CA

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

European Society of Cardiology