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Monday 28 August 2017

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Day 3

CANTOS results show anti-inflammatory therapy lowers future cardiovascular events, reduces cancer incidence and mortalityYesterday’s ESC Hot Line: Late Breaking Clinical Trials I Session marked a historic turning point in cardiology with a host of seminal, practice-changing data being presented. One of the highlights was the landmark CANTOS study that showed reducing inflammation, even in the absence of lipid lowering, significantly reduces recurrent cardiovascular events. Canak-inumab, a drug currently indicated for the treatment of interleukin-1ß driven inflammatory diseases was used to reduce inflammation. These data, that were the first to test the inflammatory hypothesis of atherothrombosis, could signal a paradigm shift in the core thinking about the treatment of atherosclerosis as they provide evidence that inflammation has a causal role in cardiovascular events. Additional exploratory analyses of the trial data examined whether anti-inflamma-tory therapy with canakinumab could change the occurrence of cancer and found that targeting the interleukin-1ß innate immunity pathway significantly reduced cancer incidence and mortality, particularly for lung cancer.

Canakinumab is a high-affinity therapeutic monoclonal anti-human interleukin-1β antibody that is designed to bind to human interleukin-1β and functionally neutralise the

bioactivity of this pro-inflammatory cytokine.Professor Paul M Ridker (Brigham and Women’s Hospital, Harvard

Medical School, Boston, USA) presented the CANTOS (Canakinum-ab Anti-inflammatory Thrombosis Outcomes Study) results, which involved patients from 39 countries. “We conducted a randomised, double-blinded trial of canakinumab involving 10,061 patients with stable coronary artery disease after previous myocardial infarction and a high-sensitivity C-reactive protein (hsCRP) level of 2mg or more per litre. The trial compared three subcutaneous doses of canakinumab (50mg [n=2,170], 150mg [n=2,284], and 300mg [n=2,263], every three months) with placebo (n=3,344). The patients enrolled were around 60 years of age, with the majority being on lipid lowering therapies and taking renin-angiotensin inhibitors,” he said.

Prof. Ridker told delegates: “Low grade systemic inflammation precedes the onset of vascular events by many years. Plasma levels of in-flammatory biomarkers, including hsCRP and interleukin-6 robustly pre-dict first and recurrent cardiovascular events, independent of lipid levels. Statins are both lipid lowering and anti-inflammatory, and the greatest benefits of statin therapy accrue to those in whom both LDL cholesterol

and hsCRP are lowered. In primary pre-vention, the JUPITER trial demonstrated that those with elevated hsCRP but low levels of LDL cholesterol markedly benefit from statin therapy. In secondary prevention, clinicians now distinguish between those with residual cholesterol risk and those with residual inflamma-tory risk. CANTOS was designed to directly test the inflammatory hypothesis of atherothrombosis, and asked the question: Can inflammation reduction, in the absence of lipid lowering, reduce cardiovascular event rates?”

The primary cardiovascular efficacy endpoint of the study was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death (MACE). The key secondary cardiovascular endpoint was MACE plus unstable angina requiring unplanned revascularisation (MACE plus). Critical non-cardiovascular safety endpoints included cancer and cancer mortality, infection and infection mortality.

The study was published in the New England Journal of Medi-cine to coincide with the ESC presentation and the cancer analysis

was simultaneously published in The Lancet.CANTOS results revealed that at 48 months there was an average re-

duction from baseline of CRP level in all groups receiving canakinumab in comparison to the group receiving placebo. The drug did not reduce lipid levels from baseline. Results revealed that at a median follow-up of 3.7 years, the incidence rate for the primary endpoint (MACE) was 4.5 events per 100-person years in the placebo group, 4.1 in the 50mg group, 3.9 in the 150mg group and 3.9 in the 300mg group. The 150mg and 300mg groups showed a hazard ratio of 0.85 and 0.86, respectively, for primary endpoint, which was statistically significant when compared to the group receiving placebo (p-trend=0.020). In terms of secondary endpoint (MACE plus), the incident rate per 100-person years in the placebo group was 5.1. It was 4.6 for the 50mg group, 4.3 for the 150mg group and 4.3 for the 300mg groups—there was a statistically significant difference between results of patients who received 150mg and 300mg canakinumab and those who received placebo (p-trend=0.003).

“The 150mg dose group, but not the other doses, met the multiplic-ity adjusted threshold for statistical significance for both the primary and secondary endpoints with a 39% reduction in hsCRP, no change in LDL cholesterol, 15% reduction in MACE and 17% reduction in MACE plus (HR 0.85 95% CI 0.76-0.96; p=0.007),” Prof. Ridker explained. Further data analysis showed that there was a consistency of hazard ratios across all cardiovascular endpoints, consistency of effects across all patients groups, and that there was greater risk reduction among those with greater hsCRP reduction.

“As shown in these data, inhibition of interleukin-1β with subcutane-ous canakinumab given once every three months among patients with

Will COMPASS point to low-dose rivaroxaban plus aspirin for patients with stable artery disease?Patients with stable atherosclerotic vascular disease who take rivaroxaban (2.5mg twice daily) plus aspirin (100mg once daily) have better cardiovascular outcomes than those who take aspirin alone, results from the COMPASS trial presented at the ESC Hot Line session yesterday revealed. These results could herald a change in guidelines in this setting, experts opined.

COMPASS results suggested that a patient group that takes the rivaroxaban-plus-aspi-rin regimen will see fewer cardiovascular

deaths, strokes and myocardial infarction, but more major bleeding events than a group that takes aspirin alone. Yet, there is no significant increase in fatal, intracranial or critical organ bleeding between these two groups and rivaroxaban-plus-aspirin provides a net clinical benefit, delegates heard. They were also told that rivaroxaban monotherapy offers no benefits over rivaroxaban-plus-aspirin or aspirin alone.

Doctor John Eikelboom (Department of Med-icine, McMaster University, Hamilton, Canada) presented data from the double-blinded, randomised COMPASS trial (Cardiovascular OutcoMes for People Using Anticoagulation StrategieS). The trial was designed to determine whether rivaroxaban in combination with aspirin or given alone is more effective than aspirin alone in reducing cardiovascular death, stroke or myocardial infarction, with acceptable safety in patients with stable atherosclerotic vascular disease. It was conducted in 602 centres in 33 countries and involved 27,395 patients. “Aspirin

is widely used for secondary prevention but is only modestly effec-tive. Warfarin trial results demonstrate the potential of anticoagu-lation to provide benefit. [Low dose] Rivaroxaban has been shown to reduce mortality post acute coronary syndrome (ATLAS ACS-2 TIMI 51),” said Prof. EIkelboom.

Rivaroxaban is a selective direct factor Xa inhibitor that is used to prevent and treat venous thromboembolism and to prevent stroke or systemic embolism in atrial fibrillation.

The researchers randomly assigned participants with stable atherosclerotic vascular disease to re-ceive rivaroxaban (2.5mg twice daily) plus aspirin (100mg once daily; ; n=9,152), rivaroxaban (5mg twice daily; n=9,117), or aspirin (100mg once daily; n=9,126). The primary efficacy outcome was a composite of cardiovascular death, stroke, or myocardial infarction.

The mean age of participants was 68.2 years, and 22% were women. Nearly 90% used lipid-lowering agents. A total of 90.6% of the participants had a history of coronary artery disease, and 27.3% had a history of peripheral arterial disease.

The independent data and safety monitoring board recommended early discontinuation of the

comparison of rivaroxaban with or without aspirin vs. aspirin alone, for clear evidence of efficacy outcome in favour of rivar-oxaban plus aspirin after a mean follow-up of 23 months.

A primary outcome event of cardiovascular death, stroke or myocardial infarction occurred in 379 patients (4.1%) who were assigned to rivaroxaban-plus-aspirin, 448 (4.9%) who were as-signed to rivaroxaban alone and 496 (5.4%) who were assigned

to aspirin alone. There was a statistically significant difference in primary outcomes between the rivaroxaban-plus-aspirin group and the aspirin-alone group (p<0.0001). However, patients in the rivaroxaban-alone group did not experience significantly fewer cardiovascular deaths, strokes or myocardial infarctions than those in the aspirin-alone group (p=0.12).

The secondary composite outcome of ischaemic stroke, myocar-dial infarction, acute limb ischaemia, or death from coronary heart

CASTLE-AF results

Andreas Grüntzig’s legacy

ESC Journal Family

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Dr. Paul M Ridker

Dr. John Eikelboom

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RACE to the top: Risk factor-driven upstream therapy results in superior sinus rhythm managementRisk-factor upstream therapy has been proven superior to conventional therapy in the maintenance of sinus rhythm in patients with early, short-lasting persistent atrial fibrillation (AF) and/or heart failure (HF) at one year. The revealing results of the RACE 3 trial were presented during yesterday’s Hot Line: Late-Breaking Clinical Trial session by Professor Isabelle C Van Gelder (University of Groningen, Groningen, The Netherlands).

“You all know that maintenance of sinus rhythm

improves AF-related symptoms. However, sinus maintenance is cumbersome due to atrial remodelling.” Prof. Van Gelder told the audience. “Risk-fac-tor driven upstream therapy refers to interventions that aim to modify the atrial substrate and, at the same time, have a favourable effect on risk factors and diseases underlying AF.”

In the prospective, open-label, multicentre trial, patients with early symptomatic persistent AF and/or HF were randomised to either upstream or conventional therapy groups, stratified by percentage of left ventricle ejection fraction. The primary endpoint of the study was the presence of sinus rhythm during at least six-sevenths of accessible time, according to seven-day Holter monitoring at one year.

One-hundred and nineteen patients were as-signed to receive risk-factor upstream therapy and 126 to undergo conventional therapy. Both groups received standard care for AF and HF according to the present guidelines. All par-ticipants received cardioversion therapy three weeks after inclusion in the study. The mean age was 65 years and 80% of participants were men. Risk factor-driven therapies were initiated in the upstream group: mineralocorticoid receptor antagonist, statins, ACE-inhibitors and/or angiotensin-receptor blockers as well as cardiac rehabilitation. All medical therapy was

titrated to the highest tolerated dosage except for statins, which were given at the recommended dosage. Target blood pressure was set at <120/80mmHg.

The upstream group took part in a cardiac rehabilitation programme, consisting of super-vised exercise—which began

immediately following inclusion and before cardioversion—and tailored counselling every six weeks to stimulate sports performance. Pa-tients took part in supervised physical activity two to three times per week for between nine and 11 weeks. Sports were encouraged for at least half an hour, five times per week, as well as medication compliance. In addition, par-ticipants were limited to <7.5g sodium intake per day, calorie intake reduction if they had a body mass index (BMI) ≥27kg/m2, and fluid restriction depending on the severity of heart failure. At one year, 75% of the upstream group achieved sinus rhythm, compared with 63% of the conventional group, resulting in an odds ratio of 1.765 with a lower 95% confidence interval of 1.115 and a p-value of 0.021.

Looking at secondary endpoints, Prof. Van Gelder said, “Blood pressure reduction was significantly larger in the upstream group, and the same was true for N-terminal pro b-type natriuretic peptide.” Both groups saw a similar increase in ejection fraction, while low density lipid reduction was significantly higher in the upstream group. No changes or differences between the groups were observed in BMI

and left atrial volume. Prof. Van Gelder said, “Therapy including treatment of risk factors and lifestyle is effective and feasible to improve the maintenance of sinus rhythm in patients with early persistent atrial fibrillation and heart failure.” The RACE 3 results were favoura-ble to the impact of upstream therapy on the reduction of risk factors, instead of its effect on atrial remodelling, she explained, concluding that “RACE 3 may contribute to the shift in focus on risk factor modification to improve outcomes in AF patients.”

“In the last few years, we have devoted a lot of effort to the symptoms and consequences of AF,” discussant reviewer, Professor Josep Brugada Terradellas, Hospital Clinic Barcelona, Barcelona, Spain, stated. “But clearly we have failed in controlling the epidemic of AF in our society.” Casting a critical eye towards the study, Prof. Brugada Terradellas noted that RACE 3 was limited by its failure to account for factors known to be associated with AF, including alcohol intake and sleep apnoea. He stated his surprise that even the control group achieved 63% sinus rhythm, and—noting the “dual epidemic” of obesity and AF—he expressed regret that BMI results were not improved in the upstream group. In spite of these limitations, he praised the study, telling the audience that it “opens the door” to future research which may demonstrate that aggressive therapy can reduce the number of patients with AF. “If we are more aggressive,” he concluded, “we might find a preventative therapy and maybe, in the future, we will reduce the burden of AF.”

a prior myocardial infarction substantially lowered the inflammatory biomarkers hsCRP and interleukin-6 and led to a significantly lower rate of recurrent cardiovascular events than placebo, while having no beneficial impact on atherogenic lipids,” Prof. Ridker said.

Immunity, inflammation and cancer “If we alter the tumour microenvironment, canakinumab could signifi-cantly reduce lung cancer incidence and mortality,” said Prof. Ridker, while explaining the basis on which investigators set out to establish whether it might alter cancer incidence. They followed patients from the CANTOS trial for incident cancer diagnoses, which were adju-dicated by an oncology endpoint committee masked to drug or dose allocation. “Subclinical chronic inflammation increases cancer. The atherosclerosis patients enrolled in CANTOS were at unusually high risk for certain inflammatory cancers, in particular lung cancer due to older age, a high prevalence of current and past smoking, and the en-rolment of only those with elevated hsCRP (which is an independent risk factor for certain cancers, in particular lung cancer),” he added.

“In these exploratory analyses within CANTOS, those allocated to canakinumab had large dose-dependent relative risk reductions in deaths due to cancer (p=0.0007), incident lung cancers (p<0.0001) and fatal lung cancer (p=0.0002). Those in the canakinumab 300mg group had a 51% reduction in cancer mortality (p=0.0009); 77% reduction in fatal lung cancer (p=0.0002); and 67% reduction in in-cident lung cancer (p=0.00008). Replication of this data is required,” Prof Ridker reported.

“In conclusion, these randomised placebo-controlled trial data demonstrate that targeting the interleukin-1β to interleukin-6 pathway of innate immunity with canakinumab reduces cardiovascular event rates and potentially reduces rates of incident lung cancer and lung cancer mortality. These data provide proof that inflammation inhibi-tion, in the absence of lipid lowering, can improve atherothrombotic outcomes and potentially alter the progression of some fatal cancers,” Prof. Ridker concluded.

In the discussant review, Malte Kelm (Dusseldorf, Germany) said: “CANTOS supports the concept of causal anti-inflammatory therapy in atherosclerosis. It offers a perspective on tailored indication, treatment and monitoring of anti-inflammatory therapy in secondary prevention in high-risk patients. The safety of the treatment has to be further evaluated in post-trial registries in cardiology and oncology, as with other anti-inflammatory agents tested in ongoing trials.”

Latest PCI research in the spotlightIn Sunday’s late-breaking science session on the Spotlight Stage, ESC delegates heard presentations on the latest research on percutaneous coronary intervention (PCI), receiving fresh data from the EARLY-MYO and RE-DUAL trials, as well as a new sub-analysis of the FAME 1 and 2 trials.

Pharmacoinvasive treatment “could be beneficial” for STEMI patientsDoctor Ben He (Shanghai, China) present-ed data on behalf of the EARLY-MYO investigators indicating that in STEMI patients presenting within six hours of symptom onset and for whom the expect-ed PCI-related delay is ≥60 minutes, a pharmacoinvasive strategy with half-dose alteplase and timely PCI is safe and shows more complete epicardi-al and myocardial reperfusion than routine primary PCI. “Primary PCI, within the guideline-recommended time window, cannot be offered to all STEMI patients,” Dr. He said. “A pharmacoinvasive strategy has, in the STREAM study and registries, been shown to be a valid alternative to primary PCI within one hour of first medical contact.”

A total of 350 patients were enrolled (175 patients in each group), and the study had an 80% power to show non-inferiority of the pharmacoinvasive strategy vs. primary PCI (to exclude a 30% worse relative outcome of the primary endpoint). The pharmacoinvasive group received half-dose alteplase (8mg bolus followed by 42mg in 90 minutes) followed by coronary angiography within 3–24 hours of randomisation or rescue PCI. The primary PCI group underwent routine PCI without fibrinolytic therapy.

The primary endpoint for the study was complete epicardial and myocardial reperfusion after PCI, defined as TIMI flow grade 3 and TIMI myocardial perfusion grade 3 with ST-segment resolution ≥70%. Core labs were allocated to blind treatment. ST-segment resolution ≥70% was reported in 51% (n=82) of the pharmacoinvasive group compared with 45.5% (n=76) in the primary PCI group (p=0.377). TIMI flow grade 3 was reported in 91.3% (n=147) of the pharmacoinvasive group compared with 89.2% (n=149) in the primary PCI group (p=0.58), while TIMI perfusion grade 3 was seen in 65.8% (n=106) of the pharmacoin-vasive group compared with 62.9% (n=105) in the primary PCI group (p=0.73). Complete reperfusion was more common in the pharmacoin-vasive group at 34.2% (n=54) compared with primary PCI at 22.8% (n=39) (p value for non-inferiority <0.05, p value for superiority=0.022).

In terms of safety outcomes, minor non-ICH bleeding was reported in 26.9% (n=47) of the pharmacoinvasive group and 11% (n=18) of the primary PCI group (p<0.001). Major non-ICHU bleeding was reported

in just one pharmacoinvasive patient (0.6%) and no primary PCI patients (p=0.497). There was no ICH bleeding in any patients.

“More clinical outcome data must be obtained to confirm the reperfusion benefit observed in this study,” Dr. He concluded. “If confirmed, a pharmacoinvasive treatment could be beneficial for eligible STEMI patients, particularly in countries without well-or-ganised STEMI networks or with significant system delays.”

Dabigatran dual therapy cuts bleed-ing risk compared with warfarin triple therapyIn atrial fibrillation (AF) patients who have undergone PCI, dual therapy with dabigatran and a P2Y12 antagonist has significantly reduced the risk of bleeding compared with warfarin triple therapy, with non-inferiority for overall thromboembolic events. In data published by the RE-DUAL PCI study group and presented yesterday by Doctor Christopher Cannon (Boston, USA), dabigatran demonstrated ab-solute risk reductions of 11.5% and 5.5% in ISTH major or clinically-rel-evant non-major bleeding at the 110mg and 150mg doses, compared with warfarin triple therapy.

The RE-DUAL PCI trial enrolled 2,725 patients with AF who had undergone PCI. They were randomly assigned to one of three groups; the first—the triple-therapy group—began triple therapy with warfarin plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and aspirin (for one to three months); the second and third groups—the 110mg and 150mg dual-ther-apy groups—received either 110mg or 150mg of dabigatran twice daily plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and no aspirin. Due to regulatory constraints, some elderly patients (≥80 years old in the USA or ≥70 years old in Japan) were randomly assigned only to the 110mg dual-therapy group or the triple-therapy group.

At an average follow-up of 14 months, Dr. Cannon reported that the incidence of primary endpoint—major or clinically-relevant non-major bleeding event during follow-up—was 15.4% for 110mg dual-therapy group as compared with 26.9% in the triple-therapy group (p<0.001 for non-inferiority and p<0.001 for superiority). The primary endpoint in-cidence in the 150mg dual-therapy group was 20.2% as compared with 25.7% in the corresponding triple-therapy group, which did not include elderly patients outside of the USA (p<0.001 for non-inferiority).

The incidence of the composite efficacy endpoint—thromboem-bolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularisation—was 13.7% in the two dual-therapy groups combined, as compared with 13.4% in the tri-ple-therapy group (p=0.005 for non-inferiority). The rate of serious adverse events did not differ significantly among the groups.

“The 110mg and 150mg dabigatran dual-therapy regimens offer all of us two additional options, with evidence, for man-aging post-PCI AF patents, with both doses approved for stroke prevention,” Dr. Cannon told the audience.

Extent of post-PCI ∆FFR linked to future adverse event rateNew subanalysis of the FAME 1 and FAME 2 trials suggests that improvement in fractional flow reserve (FFR) predicts two-year outcome after PCI, according to Doctor Stephane Fournier (Aalst, Belgium). “The higher the post-PCI FFR value, the lower the event rate, but the likelihood ratio for the occurrence of events is weak,” Dr. Fournier explained. “The larger the improvement in FFR, the lower the event rate will be.”

Dr. Fournier and colleagues investigated whether the differ-ence between FFR at baseline and post-PCI—∆FFR—impacts the two-year vessel-oriented clinical events (VOCE) rate, comprised of vessel-related cardiovascular death, vessel-related revascularisation, and vessel-related myocardial infarction.

The FAME 1 and FAME 2 studies provided the raw data for the analysis, in which 1,499 lesions were treated (pre-PCI FFR ≤0.8) including 838 lesions with post-PCI FFR measurements.

Of the patients with recorded post-PCI FFR, 277 were in the ∆FFR lower tertile (FFR ≤0.18), 282 were in the middle tertile (FFR >0.19 and ≤0.31), while 278 were in the upper tertile (FFR >0.31). Dr. Fournier and colleagues identified several predictors of ∆FFR, namely male gender (p=0.003), diabetes (p=0.024), previous PCI (p<0.001), and pre-PCI FFR (p<0.001).

The VOCE rate of these patients improved as ∆FFR increased. For the lower ∆FFR tertile the rate was 9% (n=25), for the middle tertile was 7.1% (n=20), and for the upper tertile was 4.7% (n=13) (p=0.13). While differences in the rates of death and myocardial infarction were not significant between the two groups, the differ-ence in the rates of vessel-related revascularisation—7.2% (n=20) in the lower tertile, 5% (n=14) in the middle tertile, and 2.5% (n=7) in the upper tertile—were (p=0.037). “These data indicate that the reduction in ischaemic burden is an independent predictor of vessel-oriented clinical events at two years of follow-up,” Dr. Fourier concluded. “The reason for this relationship remains speculative.”

Prof. Van Gelder

Dr. Ben He

Dr. Cannon

Dr. Fournier

CANTOS results show...Continued from page 1

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Catheter ablation of atrial fibrillation shown to reduce mortality and hospitalisations in heart failure patientsCatheter ablation of atrial fibrillation was associated with improvement in all-cause mortality and fewer worsening heart failure admissions in comparison to conventional treatment of heart failure, a trial—CASTLE AF—presented at yesterday’s Hot Line: Late-Breaking Clinical Trials 1 has found.

“The CASTLE-AF trial is novel because it is the first time mortality and hospitalisation have been used as an endpoint,” Professor Carina Blomstrom-Lun-

dqvist (Uppsala University, Uppsala, Sweden), commented in a discussant review of the study.

The results, presented yesterday by Doctor Nassir Marrouche (University of Utah Health Care, Salt Lake City, USA), indeed demonstrated a link between catheter ablation of atrial fibrillation (AF) and improved rates of all-cause mortality and worsening heart failure hospitalisation—the combined endpoint of the trial.

“AF and heart failure are well intertwined,” Dr. Marrouche ex-plained. “Catheter ablation of AF in patients with heart failure has been shown feasible.” Aiming to build on this, the team sought to assess the effectiveness of catheter ablation for AF in heart failure patients.

Three hundred and ninety-seven patients with symptomatic par-oxysmal or persistent AF were enrolled and randomised following eligibility assessment of 3,013 patients. Following exclusions during a five-week run-in period, and patient crossover between the two groups, a final total of 153 patients were treated with catheter abla-tion and 184 with conventional treatment. In addition to the primary endpoints, the team recorded secondary endpoints including cardi-ovascular (CV) mortality, and CV-related hospitalisation. Patients were followed-up from three to 60 months.

The conventional arm was treated according to the ACC/AHA/ESC 2006 guidelines for the treatment of AF in heart failure. The ablation arm underwent pulmonary vein isolation, with additional lesions ablated at the discretion of the operator. Following a blanking period, ablation was repeated.

When evaluating the effectiveness of catheter ablation accord-ing to the composite primary endpoint, the team observed a risk reduction of 38% from baseline at 60 months, statistically significant in comparison to the conventional group (p=0.007). Individually, the risk of worsening heart failure admission was reduced by 44% from

baseline in the catheter ablation group, and all-cause mortality risk was reduced by 47% in this group. Both results were statistically sig-nificant in comparison to conventional treatment (p=0.004; p=0.011, respectively).

The secondary endpoints of CV mortality and CV hospitalisation also revealed statistically significant risk reductions for catheter ablation in comparison to conventional treatment. Cardiovascular mortality risk was reduced by 51% (p=0.008) and cardiovascular hospitalisation risk by 28% (p=0.05).

Concluding, Dr. Marrouche explained, “Catheter ablation led to significant improvement in the primary composite endpoint of all-cause mortality and worsening heart failure admissions.”

“The take-home message of this trial is that it is time to offer catheter ablation procedures at an early stage in heart failure patients with AF,” she added. “But, we must be careful to select patients that reflect the populations included in this trial.”

disease occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (329 patients [3.6%] vs. 450 patients [4.9%]; p<0.0001).

BleedingMajor bleeding events occurred in more patients in the rivarox-aban-plus-aspirin group (288 bleeds [3.1%]) than in the aspirin alone group (170 [1.9%]). There were 255 (2.8%) bleeds in the group that received rivaroxaban only. There was a statisti-cally significant difference (p<0.0001) when the number of bleeds experienced by the rivaroxaban-plus-aspirin group was compared with those in the aspirin only group. However, there was no significant difference in intracranial or fatal bleeding between these two groups. Investigators also recorded a statis-tically significant difference between the number of bleeds in the rivaroxaban monotherapy and aspirin monotherapy groups (p<0.0001).

“There is a highly significant net clinical benefit observed when primary outcome and severe bleeding events are pooled together, with 431 (4.7%) of the rivaroxaban-plus-aspirin group undergoing an event as compared to 534 (5.9%) events in the aspirin monotherapy group (p=0.0005),” Dr. Eikelboom said.

Professor Eugene Braunwald (Brigham and Women’s Hos-pital, Harvard Medical School, Boston, USA) noted that the trial was an important step in thrombocardiology. “COMPASS has taken a step forward by demonstrating in stable, chronic coronary artery disease that a combination of low dose aspirin and very low dose rivaroxaban is superior to aspirin monother-apy as well as rivaroxaban monotherapy. COMPASS is a large, rigorously conducted trial with unambiguous results which, I believe, should change guidelines.”

COMPASS-PADData on peripheral arterial disease patients from the trial (COM-PASS-PAD) were presented by Professor Sonia Anand, McMas-ter University, Hamilton, Canada, that showed similar benefits with rivaroxaban-plus-aspirin in this subgroup. Consistent with the overall results of COMPASS, in PAD patients the addition of low dose rivaroxaban to aspirin, compared with aspirin alone, reduced cardiovascular death, stroke or heart attack by 28%, and limb-threatening ischaemia, including amputation, by 46%. Con-sidering both outcomes together, rivaroxaban and aspirin lowered major adverse cardiovascular or limb events by 31%.

Will COMPASS point...Continued from page 1

Dr. Nassir Marrouche

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ESC Guidelines add “S” to peripheral arterial disease to bring greater clarity

The European Society of Cardiology (ESC), in collab-oration with the European

Society for Vascular Surgery (ESVS), has produced new Guidelines on the diagnosis and treatment of peripheral arterial diseases. The “S” at the end of disease is important because it emphasises that the Guideline re-fers to all atherosclerotic diseases outside of the coronary arteries.

Professor Victor Aboyans (Department of Cardiology, Dupuytren University Hospital, Limoges, France) says that the ESC has always considered that the term “peripheral arterial disease” covers all arterial diseases that are “peripheral to the heart”, but comments the Task Force behind the new Guidelines have now added the letter “S” to the term because there is a general misconception that “peripheral arterial disease” just refers to the lower extremities. He explains that this confusion may have arisen because several papers cited the previous ESC Guidelines as just focused on lower extremities. Prof. Aboyans explains that the ESC Guidelines review carotid artery disease, upper extremity disease, and mesenteric artery disease among others.

The 2017 Guidelines include chapters on the different antithrombotic therapies available for managing peripheral arterial diseases and on potential concomitant coronary artery disease. According to Prof. Aboyans, a patient with some form of peripheral arterial disease may also have arterial disease in other sites—for example in the heart and in the carotid arteries. He notes: “We did address this in earlier Guidelines and have re-addressed the issue in these new Guidelines. But,

the new point is that patients with peripheral arterial diseases may also have cardiovascular diseases other than coronary artery disease (such as heart failure or atrial fibrillation). So, we have written specific chapters on this.”

Given that multiple specialties are involved in managing peripheral arterial diseases, the Guidelines highlight the role of the “Vascular Team”. Similar to the Heart Team concept, the Vascular Teams include a variety of experts. “For example, when

you are managing a patient with carotid artery disease, a neurologist’s opinion is also important and should be part of the team because the brain is the target organ to protect,” Prof. Aboyans comments.

The importance of the Vascular Team is why the ESC worked with the ESVS to produce the Guidelines. Past ESVS president Professor Jean-Baptiste Ricco (Department of Vascular Surgery, University Hospital of Poitiers, Poitiers, France) says that both societies highlighted the need for multidisciplinary management of patients with peripheral arterial diseases in earlier, individual Guidelines. “When the decision was made to update these ESC Guidelines, it appeared obvious that a combination of efforts from both Societies would provide the most comprehensive single document, providing updated guidelines on PADs for clinicians,” he says and notes that “it is of the utmost importance that every cardiologist should be sensitive in regard to the diagnosis and management of patients with PADs as many of them are seen and managed for concomitant cardiac conditions”.

Valvular Heart Disease Guidelines emphasise Heart Team decisions

The 2017 ESC Guidelines on valvular heart disease have put the heart team firmly

at the centre of decision making, noting that heart team collaboration is vital for ensuring optimal out-comes for the patient. They also say that transcatheter aortic valve implantation (TAVI) should be considered, with the consensus of the heart team, for aortic stenosis patients who are at increased sur-gical risk for a variety of reasons.

The rationale for the emphasis on the Heart Team—composed of experts including cardiologists, cardiac surgeons, imagers, anaesthesiologists, and even gerontologists—is to optimise management of complex patient issues. Decisions around TAVI, which require a risk/benefit analysis for the procedure compared with surgical aortic valve replacement and/or medical therapy, provide a choice example of where the wide ranging knowledge of the heart team is needed. Outside the traditionally used scores for risk stratification, factors such as frailty, the presence of a porcelain aorta or expected patient-prosthesis mismatch must be taken into account. “The message here is that you should decide according to the heart team what’s best for the individual,” explains the co-Chairperson of today’s session, Professor Jose Luis Zamorano Gomez (Hospital Ramon Y Cajal, Madrid, Spain).

The guidelines also include new data demon-strating that neurohormones can be helpful in risk stratifying aortic stenosis patients who may benefit from valve replacement.

The Task Force authoring the ESC Guidelines acknowledges that current evidence is restricted to elderly patients, since few patients under 70 years have been included in clinical trials.

The new guidelines modify the traditional guide-

line format and deliver recommen-dations in a document that is shorter and easier to read. “The summary of key points and existing gaps in evidence at the end of each section have been designed for clarity,” says Professor Volkmar Falk (Depart-ment of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin), who is co-chairing a session today on the new Guidelines with Professor Zamorano Gomez.

One tip for clinicians wanting to adopt the guidelines is to focus on Class I and Class III indications.

“Put simply, you should follow Class I indications for all your patients, and avoid Class III,” explains Prof. Gomez. The jury is still out on Class IIa and IIb indications, which may be changed into Class I or III as more information becomes available. Many Class I recommendations are supported by randomised trials (level of evidence “A” and “B”), but just because a therapy has been awarded a Class I indication with a level of evidence “C” (expert consensus), it does not mean that it is not of major importance. “We know that some treatments are valuable without clinical trials. For example using a parachute when jumping out of an aeroplane would have a Class I-C recommendation as you’d obviously never perform trials to test whether it was effective,” he says.

Prof. Falk concludes: “New knowledge in valvu-lar heart disease emerges constantly. While it is not useful to change clinical practice with every new trial, regular updates are considered mandatory.”

ESC Guidelines 2017 - Valvular Heart Disease08.30–10:00; Barcelona - Main Auditorium

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40 years of angioplasty, and the man who made it possibleThis year marks the 40th anniversary of the first coronary angioplasty, which was performed by Doctor Andreas Roland Grüntzig on 16 September 1977. ESC Congress News charts the evolution of the procedure, and examines the life of the pioneering doctor who created it.

In 1969, Dr. Grüntzig moved to Zurich (Switzerland) to work in internal medicine with Professor Robert Hegglin. Unfortunate-ly, Doctor Hegglin died suddenly shortly afterwards and Dr.

Grüntzig was “orphaned”. However, as serendipity would have it, a new division had opened up at Zurich—angiology, focused on treat-ing atherosclerosis in the peripheral arteries—and Professor Alfred Bollinger, the head of the new department, adopted (in a fashion) Dr. Grüntzig. Professor Bernhard Meier (Cardiovascular Department, University Hospital of Bern, Bern, Switzerland), who worked with Dr. Grüntzig, comments: “It meant he got immediate contact with atherosclerosis in the leg arteries, which was excellent training.”

It was during this time that Dr. Grüntzig became aware of the work being done in the USA by Professor Charles Dotter, who was using a crude technique to open up narrowed leg arteries. Accord-ing to Prof. Meier, Dr. Grüntzig started to use the Dotter technique but, thinking about expanding its use to the coronary arteries, immediately saw it was too primitive and set about improving it. “That is when he thought about using a balloon. And, again, an act of serendipity occurred. Just across the street from the hospital was the Technical University of Switzerland, and there he found a plastics expert who helped him to create the balloon. He wanted one that was cylindrical and could inflate to high pressure—that would get hard without assuming a spherical shape. The engineer suggested polyvinyl chloride,” he continues.

Dr. Grüntzig then worked with a small medical device com-pany in Zurich that specialised in catheters to help him make the balloon. The story that he perfected the balloons at his kitchen table is, in fact, true. Prof. Meier explains: “He got the materials from the plastics industry, and the idea of how to do it from the engineer, but then he had to try it himself. So he used his kitchen—not only the table, but also his kitchen stove to heat the balloons that were subsequently used in legs of patients. Today, that would no longer be possible!”

History was made on 16 September 1977 when, after his successful home experiments, Dr. Grüntzig performed the first-in-human coronary angioplasty procedure. He dilated a short non-branching segment of the left anterior descending (LAD) cor-onary artery which had a high grade stenosis. The immediate out-come was good, and the patient became and remained angina-free. Grüntzig presented the results of his first four angioplasty cases at

the 1977 American Heart Association (AHA) meeting, which led to widespread acknowledgement of his pioneering work.

However, despite this success, Dr. Grüntzig recognised that the treatment may not be readily accepted by some physicians—par-ticularly cardiac surgeons but also internists and even fellow car-diologists. Also, he knew that careful patient and lesion selection was required to reduce the risk of poor outcomes as was careful training of operators. His cautious approach paid off as his efforts are now widely credited with being of fundamental importance to the ultimate success of the technique.

Prof. Meier joined Grüntzig’s team in 1976 and says that the father of interventional cardiology was a person of “great charm,

eloquence, and wit”. He says: “He knew that he was good. It wasn’t arrogance, but he was sure of himself. Without him, my career would certainly not have been what it was. Those who worked with him were part of an absolutely stunning development in cardiology.”

Dr. Grüntzig did have plans for another innovation but these never came to fruition—his life and career were tragically cut short when he died, aged 46, in a plane crash with his second wife in 1985. Prof. Meier explains: “He always told me ‘this is not the last thing I have developed; I will go on to other ideas.’ He clearly wanted to have at least one more pivotal innovation. But he died too young to prove or disprove it. I have no idea what it would have been, and I think he had no idea himself, but he was looking around for one and then he died.” Even with his first invention, Grüntzig made a major contribution to medicine by demonstrating that doctors could safely work inside arteries, without the need for open surgery. Alas, in a cruel twist of fate, Dr. Grüntzig did not live long enough to see the true impact of his breakthrough procedure. One year after his death, in 1986, Puel implanted the first (self-expanding) coronary stent and one year later, in 1987, Palmaz and Schatz presented the first balloon-expandable stent. Only thereafter did the method initially devised by Andreas Grüntzig develop to its true potential.

Dr. Andreas Grüntzig

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Let’s Talk about Strategy - Interventional approaches from easy to complex anatomy

14:00–15:30; Spotlight Stage

New interactive session to explore different PCI strategiesA new type of session—Let’s Talk about Strategy—launches at ESC Congress 2017 today. The aim of the session is to collect opinions from a panel of experts by putting them on the spot, looking at how they would treat a particular case and why they decide in a certain way. In keeping with this year’s Spotlight on 40 years of percutaneous coronary intervention (PCI), the session will focus on different PCI cases ranging from the simple to the more complex.

ESC Congress Programme Committee Chairperson, Professor Stephan Achenbach (Department of Cardiology, Friedrich Alexander Universität Erlangen-Nürnberg, Erlangen, Germa-

ny)—who is moderating the session with Professor Spencer King (Emory Heart Center at Saint Joseph’s Hospital, Atlanta, USA)—ex-plains: “The moderators will show a coronary angiogram and will ask the panellists in turn how they would treat the lesion that is shown.” He adds that what will be interesting is to see if the panellists agree about how the lesion should be treated, commenting: “Experts do not always agree and can often have different opinions from each other”.

The experts will not only discuss how they would manage a case but will also explore why they would manage it in a particular way. “It is always good to hear and understand the reasons behind choosing a par-ticular strategy—for example, why one expert would use one stent rather than two or three and in which sequence they would be placed. By listening to their views at this session, you can gain an insight into their thought process,” Prof. Achenbach comments. He adds that those attending the session will be encouraged to interact with the panellists via the ESC Mobile App: “Voting cards in two different colours—for yes and no—will be distributed so that the panel can collect the audience’s opinion on a given case.”

The session is part of the commitment of the ESC Programme Committee to create more interactive formats to disseminate knowledge. “Let’s Talk about Strategy will be a unique learning experience in a new, fast-paced format. So, come and be part of this premier session,” Prof. Achenbach says.

The expert panellists at the session are Professor Antonio Colombo (Unit of Cardiovascular Interventions, Istituto Di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy), Doctor Jean Fajadet (Clinique Pasteur, Toulouse, France), Professor Martin B Leon (Center for Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York, USA), Doctor Julinda Mehilli (Department of Cardiology, Munich University Clinic, LMU, Munich, Germany), Professor Helge Möllmann (Department of Cardiology, Johannes Hospital, Dortmund, Germany), and Profes-sor Helge Möllmann (Department of Cardiology, Johannes Hospital, Dortmund, Germany).

Abstract of the day: Study confirms prior infective endocarditis carries greatest risk of the conditionResults from a Danish study support both European and US guidelines by finding that people with a history of infective endocarditis have a significantly greater risk of developing the condition than the general population.

Investigators Doctor Lauge Ostergaard (Rigshospitalet – Copenhagen University Hospital, The Heart Centre, Copenhagen,

Denmark) and others observe that both Euro-pean and US guidelines state that patients with prior infective endocarditis, a prosthetic heart valve or cyanotic congenital heart disease are all at increased risk of developing infective endocarditis. However, in their abstract, they note: “Knowledge is sparse on the relative risk between these three groups and compared with controls”.Therefore, using data from Danish nationwide registries, they sought to identify the incidence of infective endocarditis

among these “high-risk” groups and compare this incidence with that of gender-matched controls. Of 24,253 patients, 5,192 had prior endocarditis, 17,241 had a prosthetic heart valve, and 1,820 had cyanotic congenital heart disease. The authors report: “The cumulative risk of infective endocarditis over 10 years was 10.4% for prior endocarditis, 3.4% for a prosthetic heart valve, and 1.1% for those with cyanotic congenital heart disease. All groups carried a significant higher risk of infective endocarditis than matched controls from the general population. These findings justify the European and American guidelines.”

Come to today’s session to see how a panel of PCI experts will treat this case

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Imaging quiz: What’s your diagnosis?

BROUGHT TO YOU BY THE EUROPEAN ASSOCIATION OF CARDIOVASCULAR

IMAGING (EACVI)

Three-dimensional CT angiography of the heart in a 53-year-old patient with shortness of breath.

Stephan Achenbach, Friedrich-Alexander University Erlangen-Nürnberg, Germany.

See page 9 for solution.

Where next for PCI versus CABG?Saturday and Sunday saw a host of Late-Breaking Science trials that provided further insights into the safety and efficacy of contemporary percutaneous coronary intervention (PCI). For example, on Saturday, results of the SYNTAX II study showed that state-of-the-art PCI yields fewer adverse events in de novo three-vessel disease. However, the question remains—when should PCI be used and when should surgery be preferred? Professor Michael Haude (Medical Clinic I Lukas Hospital, Neuss, Germany) explores recent evidence regarding the use of of PCI versus coronary artery bypass grafting (CABG) for coronary revascularisation.

SYNTAX II is a European multicentre single-arm study that compared outcomes of patients (450) with de novo three-vessel disease undergoing PCI with contemporary

techniques (such as next-generation drug-eluting stents) with patients who underwent PCI in the first SYNTAX trial. This trial, which compared PCI with a first-generation drug-eluting stent with CABG, found that the more disease present, the greater the benefit of surgery (versus PCI). However, it also showed that left main PCI was associated with similar out-comes to those of surgery.

Following SYNTAX, the EXCEL study found that left main PCI was associated with a similar rate of death, stroke, and myocardial infarction as was surgery at three years. However, another study that was published at the same time as EXCEL—NOBLE—found that PCI was associated with a significantly higher rate of major adverse cardiac and cerebrovascular events at five years compared with CABG. According to Prof. Haude, these apparently opposing results are not as conflicting as they may seem and both support the findings of the original SYNTAX study. He says: “If you have single-vessel left main disease, or limited additional disease, the results between surgery and PCI are equivalent. And, the more distal disease you have to the left main, the more favourable it is to surgery. NOBLE and EXCEL didn’t change that; it was already known from a subgroup analysis of SYNTAX.”

Furthermore, he notes that—compared with CABG—repeat revascularisation is the “Achilles heel” of PCI, stating: “There is no difference in cardiovascular mortality or myocardial infarction between PCI and CABG. But when you include revascularisation among the endpoints, we always have more reinterventions with PCI.”

Subgroup analyses of PCI versus CABG trials, including SYNTAX, demonstrate that complete revascularisation PCI (both culprit and non-culprit vessels), in the acute setting, has similar rates of revascularisation to surgery in what Prof. Haude calls a “reasonable timeframe, which means two years”.

But, he adds: “We need to see what is going to be happening in five and 10 years to find out whether outcomes with PCI are still as good as they are for CABG.”

Also, with PCI, revascularisation may occur because further stenoses can develop in the vessel that has been treated. But, as most of the arterial bed is being bypassed, CABG does not have this issue. “PCI is only treating the tip of the iceberg. Therefore, challenging CABG outcomes in the long term will be extremely difficult. PCI is only treating the emerging ste-nosis but not the underlying complete atherosclerotic process in the arterial wall especially outside of the stented vessel seg-ment,” he observes. Additionally, the durability of the—nowa-days more frequently used—arterial grafts is another factor in favour of CABG.

However, since the original SYNTAX trial, developments in PCI technology—such as next-generation drug-eluting stents that have thinner struts and more flexibility—have enabled lesions that previously would have been too complex for PCI to come within its scope. Also, the SYNTAX score II has op-timised decision-making between CABG and PCI. Unlike the anatomical SYNTAX score, it is based on clinical characteris-tics as well as anatomical characteristics.

Looking to the future, Prof. Haude says that bioresorbable scaffolds still have thepotential to improve on existing devic-es and even possibly be equivalent to surgery. He comments: “There is still hope with the improved technology of the second-generation devices [there have been some limitations with the first-generation devices]. But, these newer devices have to be compared in randomised controlled trials against current drug-eluting stents to show that they, at least, are non-inferior to those devices before they can be evaluated against CABG.”

Prof. Haude is Chairperson, alongside Doctor Marie-Claude Morice (Institut Cardiovasculaire Paris Sud, Paris, France), at today’s 40 years of percutaneous coronary interventions and beyond (16:30–18:00; Bishkek - Village 6).

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Could SPRINT change BP management in elderly patients?

SPRINT (Systolic Blood Pressure Interven-tion Trial) indicated that aggressive man-agement of blood pressure (BP) in older

people significantly reduces mortality—contrary to the belief that BP targets for elderly patients do not need to be as low as they are for younger patients. However, a specific method to measure blood pressure was used, which is likely to have had substantial influence on trial results. ESC Congress News explores whether it is time for clinicians to reduce target BP in elderly patients.

Blood pressure management in the elderly may be due for a rethink following recent trial results. The definition of elderly is 65 years, but the literature also cites a group known as the “older old” (those aged >75–80 years). Current ESC recommended hypertension targets are <140/90mmHg for those aged <80 years and <150/90mmHg for those >80 years.

However, Doctor Luis Miguel Ruilope (Instituto de Investigacion, University Hospital, Madrid, Spain) told ESC Congress News that although evidence from the HYVET (Hyper-tension in the Very Elderly Trial) trial supports higher optimal BP targets in elderly patients than in those who are younger, results from the 2016 SPRINT study challenge this view.

The SPRINT trial evaluated the effects of inten-sive (<120mmHg) systolic blood pressure (SBP) targets compared with standard (<140mmHg) targets in persons aged ≥75 years with hypertension but without diabetes. Follow-up data were available for 2,636 participants in the multicentre randomised trial, and showed that treating to a blood pressure target of <120mmHg SBP led to significantly lower rates of fatal and non-fatal major cardiovas-cular events and death from any causes than in the group treated to an SBP target of <140mmHg. The authors of the study say that the “participants … are representative of a sizeable fraction of adults in this age group with hypertension”, in terms of frailty

and chronic con-ditions. “SPRINT used a different methodology to measure BP, similar to automated office BP (AOBP). That is unattended, and gives lower BP values. To apply the results of SPRINT, an AOBP measurement has to be used. It has been criticised, but in my opinion SPRINT validated this methodology to measure BP,” Dr. Ruilope comments.

HYVET randomised patients aged ≥80 years to therapy with indapamide, with or without an angiotensin converting enzyme inhibitor, or to placebo, with a blood pressure goal of <150mmHg. The two-year between-group SBP difference was 15mmHg, with the active treatment group in HYVET achieving a slightly higher mean BP than the baseline in the SPRINT study. Both studies were terminated early due to significant reductions in the incident rate of mortality.

However, Dr. Ruilope warns of potential problems with lowering BP targets—comment-ing: “The biggest pitfall corresponds to isolated systolic hypertension where an intensive drop in BP could be dangerous. This relates to the J-shaped curve.” Also, he advises clinicians: “The key factors to consider when managing an elderly patient with hypertension are frailty, the safety of their medications, the presence of comorbidities, and whether there is established cardiovascular and renal disease.”

Furthermore, according to Dr. Ruilope, it is important to take into account both biological and chronological age. He notes: “The biological age relates to the status of the cardiovascular and renal system that can be functionally maintained in the presence of an elevated chronological age.”

Dr. Luis Miguel Ruilope

Sports cardiology: The conundrum of distinguishing physiological adaptations

In an interactive session yesterday, leading sports

cardiologists discussed the “conundrums” facing clinicians screening athletes in distinguishing nor-mal physiological

cardiac adaptations to exercise found in athletes from the diseased state.

Sports cardiology, defined as a subdiscipline of cardiology, takes into account modifications made by exercise to the cardiovascular system. “There’s a real danger that cardiologists who aren’t accustomed to seeing sports people can make the mistake of diagnosing these differences as cardio-vascular diseases,” says Professor Antonio Pelliccia (Institute of Sport Medicine and Science, Italian National Olympic Committee, Rome, Italy). Such physiological changes, he adds, affect not only professional athletes, but also normal individuals engaging regularly in exercise. And with large proportions (10% to 20%) of the global population engaging regularly in exercise, such changes may be far more widespread than appreciated.

In the first presentation of yesterday’s session, Professor Stefano Caselli (Department of Cardi-ology, Institute of Sports Medicine and Science, Rome, Italy) explored whether the presence of pathologic trabeculations can be used to diagnose left ventricular non-compaction cardiomyopathy (LVNC). When the process of “compaction” of normal ventricular myocardial trabeculations fails during early embryogenesis, the remaining trabeculations appear as loose networks of muscle fibres separated by recesses (in imaging studies). In a study published last year, Prof. Caselli showed that out of 2,501 consecutive athletes screened, 1.4 % (36) showed prominent trabeculations suggestive for LVNC. However, on follow-up only

0.1% (three) of these athletes had morphologic and clinical evidence supporting the diagnosis of LVNC (International Journal of Cardiology, 2016; 223: 590-595). Such data, Prof. Caselli argued in the session, indicate that trabeculations are far more widespread than appreciated and that there is a need to give greater weight to clinical information (such as LV dysfunction, positive family histories and genetic testing) to reach diagnosis of LVNC.

Doctor Michael Papadakis (Department of Molecular and Clinical Sciences, St. George’s Uni-versity of London, London, UK) then considered how right ventricle remodelling, as a physiological adaptation to exercise, can overlap with morpho-logical changes occurring with right ventricular cardiomyopathy.

Finally, Prof. Pelliccia drew on his own work screening Olympic athletes in his quest to define the most extreme “normal” physiological adaptations that can occur with sport. “We want to be able to take into account factors such as the impact of different sports, genders and ethnic origins,” he said.

To provide greater clarity in the field of sports cardiology, a spate of position papers has been pub-lished in the last year. The European Heart Rhythm Association (EHRA) and European Association of Preventive Cardiology (EAPC) recommended appropriate diagnostic methods for pre-participation cardiovascular evaluation; and an international con-sensus statement has been produced on electrocardi-ographic interpretation in athletes. “We really think these publications should help physicians to identify individuals at risk by reducing at the same time the number of false positives,” says Prof. Pelliccia.

Also currently undergoing revision is the consen-sus document on recommendations for competitive sports participation in athletes with cardiovascular disease, published in 2005. “We’re hoping to pro-duce a comprehensive document providing criteria for assessing individual risk, strategies to approach exercise safely and advice on what types of exercise individuals can safely perform,” says Prof. Pelliccia.

The ESC Journal Family is breaking new groundThe ESC publishes a broad range of journals, from the flagship European Heart Journal (EHJ) to the recently launched EHJ – Case Reports. This spectrum of 13 journals—the largest range of cardiovascular journals in the world—represents a true family because the Editorial Boards behind the journals help each other to produce the best-possible publications.

Professor Thomas F. Lüscher (Zurich Heart House, Zurich, Switzerland), the Edi-tor-in-Chief of the EHJ, says that the goal

of the ESC Journal Family is to “provide a compre-hensive, complete and wide-ranging educational programme” for the members of the ESC and for “anyone with an interest in cardiology”. He adds that as the vast majority of ESC members are general cardiologists, they will see patients with all kinds of cardiovascular problems and need to know about sev-eral different areas of cardiology. Therefore, the scope of the EHJ is to cover all aspects of cardiology.

Three print journals look at different elements of cardiology (EHJ - Cardiovascular Pharmacotherapy, EHJ - Quality of Care & Clinical Outcomes, and EHJ - Cardiovascular Imaging) plus there is the new online EHJ – Case Reports (an open access journal). The remaining eight journals focus on specific areas of cardiology to cater to the educational needs in those areas. Each journal is run by members of the ESC Association, Council or Working Group that relates to the topic of the journal—for example, the Editorial Board of the European Journal of Heart Failure are members of the Heart Failure Association.

However, Prof. Lüscher explains that a fine balance has to be struck between providing specialists with their own journal and not having so many journals that they start to compete with each other. “The danger is if we publish too many, we will dilute the importance of the individual journals,” he says. The aim of the ESC Journal Family is to complement each other. Furthermore, the individual Boards reg-ularly liaise with each other, in particular to transfer manuscripts so that submitted studies are published in the most relevant journal. “Previously, we just

used to have a range of products, but we really have made an effort to make the ESC Journal Family a real family and families help each other out. Therefore, we introduced the concept of manuscript transfer. For example, at the EHJ, we have transferred hundreds of heart failure manuscripts to the European Journal of Heart Failure. We have done an analysis of this and discovered that when heart failure papers are trans-ferred to the European Journal of Heart Failure they receive many more citations as compared to those directly submitted to the European Heart Journal.” Thus, the manuscript transfer works for the benefit of the entire ESC Journal Family.

Citations are all important for journals because they affect a journal’s impact factor. Indeed, the impact factor of the EHJ—now 20.213—shows just how successful the journal has become since the current editorial team in Zurich took over in 2009. However, for Prof. Lüscher, the number of downloads a paper receives is just as important as the impact factor—in fact, he calls the number of downloads the “influ-ence” of a paper or journal. “The influence of the EHJ is impressive. When we took over, it had 2 million downloads and now we have 8 million downloads. This is a huge change and shows that the papers we publish prompt so much interest that people download them. Hopefully, they read them as well and implement the knowledge gained and know-how in their clinical practice”. Another marker of success of the EHJ is that—despite having “Europe” in the title—it is a global journal. “We have editors from all over the world; from the USA, Japan, China, and, of course, Europe,” Prof. Lüscher comments.

The impact and influence of the journal are important for authors as well as being important for

the journal itself. Prof. Lüscher notes: “An author who submits a paper wants that paper to be seen by as many people as possible; they want to be cited, they want to impact science and medicine.” One way in which the ESC Journal Family seek to improve the number of citations of papers, of all their journals, is to work with companies such as Kudos. Charlie Rapple, co-founder of the company, says: “Kudos provides a way for researchers to increase the readership and impact of their work in two key ways. It is a free tool for adding a plain language summary of their work, which helps more people to find and understand it, and for managing efforts to communicate their work more effectively. It also gives each researcher a dashboard of metrics, for all their articles—including those in one of the ESC Journal Family publications—and generates trackable links for each of those publications.” According to Michael Alexander, ESC Head of Publications, “One objective for the coming year, in collaboration with our publishers OUP, SAGE and Wiley, is to provide ESC Journal Family contributors with additional services. Kudos helps authors promote their work, Publons helps quantify the academic input of our reviewers, Altmetric measures the influence Prof. Lüscher mentioned and ORCiD will help our wider

community tie together in one place all of their scien-tific and academic contributions.”

In fact, one of the goals of the latest journal in the family (EHJ – Case Reports) is to encourage cardi-ologists at the start of their career to write and submit articles to a journal. Editor-in-chief Professor John Camm (St. George’s University of London, London, UK) explains: “We wanted a journal that would be appropriate for young writers; cardiologists who ha-ven’t had an opportunity of doing extensive research but may have come across an interesting case. Our aim is to encourage them to write about these case reports, particularly as other journals in the family are inundated with case reports that they cannot publish.”

The new journal is online only because authors are charged a nominal fee for publishing their case reports and the Editorial Board wanted to avoid the cost of printing. However, Prof. Camm observes: “All journals are going to be online only eventually; it is only a matter of time.” He adds that, to take full advantage of the online-only status of the journal, the Editorial Board is building a social medial profile to help promote those vital citations and downloads.

Therefore, whatever your interest, whether you are a reader or an author, the ESC Journal Family has a journal that suits your needs.

Prof. Antonio Pelliccia

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“By getting together, we might actually change the world and make a difference in stroke”A group of health professionals came together in 2015 to form the AF-SCREEN International Collaboration—a consortium that seeks to promote the case for screening for atrial fibrillation (AF). ESC Congress News reviews the arguments for AF screening and looks at the work of AF-SCREEN, specifically its White Paper recently published in Circulation.

Professor Ben Freedman (Heart Research Institute/the Charles Perkins Centre, Sydney, Austral-

ia) formed AF-SCREEN with five other cardiologists to promote discussion and research about AF screening, and to advocate for implementation of country-specific programmes. The consortium now has more than 130 members from 33 countries, including many of the foremost names in AF re-search. It includes many different types of physicians as well as cardiologists, allied health professionals and nurses,

epidemiologists and health economists and lay organisations. He sees the con-sortium as a great opportunity to make a real difference, commenting: “If we went back in time and found asympto-matic AF before an AF-related stroke occurred, you could potentially prevent 10% of all ischaemic strokes. This is doubly important because AF-related strokes tend to be at the severe end of the spectrum—people either die or have a severe, disabling stroke. AF represents a rare opportunity in which there is a common condition that causes horrible

outcomes that could be prevented if you find it in time and then do something about it.”

AF-SCREEN’s White Paper calls for screening programmes—aimed at people ≥65 years of age—that could use pulse palpation, oscillometric (blood pressure) or photoplethysmographic (smartphone camera) devices, and handheld ECG devices to diagnose AF. Because an ECG rhythm strip is required to verify the diagnosis, hand-held ECG devices are preferred. The paper also recommends more intensive monitoring for some patient groups, such as those with recent embolic stroke of uncertain source (ESUS).

Prof. Freedman says: “You need to look for atrial fibrillation in people who are of an age where it’s much more common to get it and, if they have it,

the risk of stroke is high enough to war-rant treatment. A screening programme could be part of a routine health check or chronic care assessment, particu-larly in the over 65 year olds. Routine checks like these start at age 65 in many countries and, in the USA, Medicare kicks in then. It would work best if you could add screening to an already-es-tablished workflow, as it is only a small additional part.”

The White Paper also says AF screening should be individualised according to country and healthcare system-specific requirements and resources, and should also be linked to an effective pathway for appropriate diagnosis and management.

The final key point in the paper calls for large randomised controlled studies, using hard endpoints (including stroke,

systemic embolism, and death), of strat-egies for screening that will strengthen the evidence base to inform guidelines and national systematic screening programmes.

The White Paper’s publication comes just ahead of a Hot Line session tomorrow at which results will be presented from a late-breaking trial on screening for AF. The senior investiga-tor Professor Julian Halcox (Swansea University Medical School, Swansea, UK) is a member of the AF-SCREEN consortium.

Hot Line: Late-Breaking Clinical Trials 429 August08:30–10:00: Barcelona - Main Auditorium

Imaging quiz solution: Patent ductus arteriosus (PDA)The three-dimensionally reconstructed CT angiogram (left) and a two-dimensonal image (right) show a patent ductus arteriosus (PDA, arrows), connecting the aorta (Ao) and pulmonary artery (PA).

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Find the right balance of antithrombotic therapy in PCIAntithrombotic treatment for patients during and after they undergo percutaneous coronary intervention (PCI) has been the subject of much debate and uncertainty. This overview looks at the current status of antithrombotic therapy in this context, and examines data from recent trials and their impact on treatment options.

Existing an-tithrombotic therapy during

and after PCI consists of the mandatory use of aspirin, intravenous (IV) anticoagulation (such as unfractionated heparin, low molecular weight heparin, or biv-alirudin), and a P2Y12 inhibitor (clopidogrel for stable patients, and

prasugrel or ticagrelor for those with acute coronary syndrome [ACS]). In addition, GP IIb/IIIa inhibitors (GPIs) are optional drugs that can be used either in bailout situations in patients at high thrombotic risk, or in ST-segment elevation myocardial infarction (STEMI), especially in patients who have received early treatment after symptom onset, particularly young people with low bleeding risk.

Professor Gilles Montalescot (ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France) says that further data for the best treatments are needed: “The timing of the administration of P2Y12 inhibitors has been evaluated by two randomised studies, one in STEMI with ticagrelor, and one with prasugrel in non-STEMI (NSTEMI). But whether the conclusions from each study can be applied to the other drug is unknown, and interpreting the results as class-effect or a specific drug-effect remains difficult.”

“Globally,” he adds, “important progress has been made with antiplatelet agents, and limited progress with anticoagulation in PCI.” He points to the fact that around 15 randomised studies have produced data on the optimal duration of dual antiplatelet therapy (DAPT) after PCI.

“It appears the shorter the better for the prevention of bleeding, with the shortest duration tested being two to three months in

these trials. Long DAPT treatments—that is >1 year—may be useful in selected patients, for example, those at low bleeding risk and without bleeding during the first year of treatment, when they are believed to be at high ischaemic risk, in particular those with a prior myocardial infarction, as shown in PEGASUS.”

The 2015 PEGASUS trial (published in The New England Journal of Medicine; NEJM) evaluated the long-term use of tica-grelor in patients with prior myocardial infarction (MI). All of the 21 162 participants had had an MI between one and three years previously. The double-blinded randomised trial assigned them to a twice daily dose of either 90mg ticagrelor, 60mg ticagrelor, or placebo. Patients also received low-dose aspirin, and were fol-lowed for a median of 33 months. Treatment with ticagrelor sig-nificantly reduced the risk of cardiovascular death, MI, or stroke, but increased the risk of thrombolysis in myocardial infarction (TIMI) major bleeding without a reduction in total death. The study’s authors suggested that the 60mg dose may offer a more attractive benefit-risk profile, although the difference between the two doses was not significant.

Nowadays, Prof. Montalescot comments, with the advent of new-generation drug-eluting stents (DES) the type of stent does not influence the duration of DAPT following PCI as it was the case with the first-generation of DES. “New-generation DES can be used in all patients. Studies such as LEADERS FREE and ZEUS have shown that one-month DAPT can be used in DES-treated patients with better results than in BMS-treated patients,” he observes.

In 2014, the DAPT study (published in NEJM) of 99 61 patients demonstrated that extending DAPT beyond one year after the placement of a DES significantly reduced the risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events, compared with aspirin therapy alone, but it was associated with an increased risk of bleeding and no reduction in total death (with even a trend towards increased total mortality). In addition to aspirin, participants were randomly assigned to continue to receive a thienopyridine drug (clopidogrel or prasugrel), or a pla-cebo for 18 months; this followed on from 12 months of treatment with either clopidogrel or prasugrel. The reduction in the risk of ischaemic events was consistent across stent type and specific thienopyridine drug used, and was evident regardless of the risk of stent thrombosis.

But Prof. G Montalescot believes patient characteristics are more important when determining DAPT duration than choice of stents, noting: “A prior history of bleeding, being elder-ly, being female, and renal insufficiency are major factors that are associated with bleeding risk. In these cases, DAPT should be shortened.”

There are now tools to aid physicians in determining the optimal duration of DAPT. One of these, PRECISE-DAPT, was published earlier this year. The PRECISE-DAPT collab-orative study (published in The Lancet) developed a scoring system that can be used to predict the risk of out-of-hospital bleeding in patients receiving DAPT after undergoing PCI. The 14 963 patients were prescribed DAPT, usually aspirin and clopidogrel. The primary endpoint of out-of-hospital bleeding occurred in 218 patients, of whom 124 had a major bleeding event. Using Cox proportional hazards regression, the investigators identified predictors of out-of-hospital TIMI major or minor bleeding stratified by trial, and devised a sim-ple five item numerical bleeding risk score based on patients’ age, creatinine clearance, haemoglobin, white cell count at baseline, and previous spontaneous bleeding.

The ESC is a proud partner in the development of biomedical code of ethics

T ransparency, objectivity and ethical integrity are critical in maintaining

public confidence in today’s society, which is becoming more discerning and aware of financial irregularities, whether real or implied. Therefore, the ESC has played a key role in the development of a code of conduct for healthcare professionals through its membership of the Alliance for Biomedical Research in Europe. The Alliance is a unique body that was created in 2010 to bring together 20 leading European research-driven biomedical societies, and has a membership of more than 400,000 researchers and health professionals.

The ESC was instrumental in the creation of the ethical code, which is founded on the core values of hu-manity, integrity, quality, independ-ence, respect, accountability, and transparency. The code outlines prin-ciples for members to adhere to in the areas of representation activities (for example, advocacy), continuing medical education, continuing pro-fessional development, congresses, publications, research funding, regis-tries, clinical practice guidelines, and exhibitions where pharmaceutical products are promoted.

ESC Past President 2014-2016, Professor Fausto Pinto (Dean of Faculty of Medicine, Universidade de Lisboa, Portugal) believes that the code of ethics is a valuable tool: “The Biomed Alliance is an interna-tional, non-profit organisation that

includes all major scientific societies in Europe. It is very important that scientific societies develop their own rules, which should be followed by all. This is particularly relevant in the current global environment where other structures and organisations, including industry, are developing rules that they wish to impose on scientific societies. From our per-spective, this is totally unacceptable since, in many cases, it collides with our values and principles as inde-pendent scientific societies.”

The stated mission of the Alliance is to be a collective European voice for its members. It aims to achieve this through internal discussion to crystallise ideas, networking, establishing visibility, standing, and credibility, and through lobbying at an EU level.

Both the President of the Alliance for Biomedical Research in Europe, Professor Colm O’Morain (Meath/Adelaide Hospitals, Tallaght, Dublin, Ireland) and Board member Professor Axel R Pries (Dean of Charité Univer-sitätsmedizin Berlin, Berlin, Germany) stress the importance of the ESC’s active participation in the group. In a joint statement, they say: “We empha-sise a multidisciplinary approach. By joining forces across many societies, a comprehensive, interdisciplinary, and powerful voice for biomedical research and its medical application in Europe can be generated.”

Prof. Pinto agrees: “The ESC is proudly part of the BioMed Alliance.

At the ESC, we believe that by working together with other scientific societies, science will have a stronger voice to promote the best possible medical and scientific practices around Europe.”

He continues: “The Alliance is committed to promoting excellence in European biomedical research and innovation, with the goal of improv-ing the health and wellbeing of all European citizens. Its member organ-isations offer essential, fair, balanced, and unbiased continuing professional education; diagnostic and treatment guidelines to ensure the highest scientific and medical standards; and evidence-based scientific progress, in order to enhance patient care.”

The group’s achievements to date include the establishment of a status paper on animal experimentation and alternatives, and an analysis of EU framework funding schemes, as well as triggering the setting up of a scientific panel for health to advice the EU commission.

Prof. Axel Pries says: “Ongoing projects include attempting to secure the role of medical societies in train-ing and education—the taskforce of which is chaired by Professor Jeroen Bax, the ESC President—to improve conditions for investigator-led clini-cal trials, to influence EU framework funding schemes, and to develop a vision for a European council for health research.”

For more information, see: www.biomedeurope.org/

Prof. Gilles Montalescot

Get the Barça experience at Camp Nou

Delegates looking to sample the delights of Barcelona would be well advised to take in a

visit to the iconic Camp Nou, stadium for the city’s eponymous football team, FC Barcelona.

One of Europe’s largest, the stadi-um is home to some of the world’s most expensive and celebrated footballers. But Camp Nou (“new place” in Catalan) is more than just a football stadium. It has played an integral part in the city’s history and development, and is held in high regard by Catalonians.

The stadium boasts a tour, and a

museum that is one of the most visited in Europe; it is open every day of the year apart from 1 January and 25 December. With tickets available from €20, the tour lasts from 1.5 to two hours and allows visitors to experience the thrill of walking out onto the Camp Nou pitch, exploring the Messi area, and marvelling at the five European cups won by the team, as well as the many domestic trophies.

FC Barcelona is currently placed second in La Liga, the Spanish football league, behind their rivals Real Madrid.

For more information, see: www.fcbarcelona.com/tour/buy-tickets

“The PRECISE DAPT score assesses the risk of bleeding, while a second tool, the DAPT score, assesses the

global risk of the occurrence of both ischaemic events and bleeding.”

State of the art in platelet biology11:00–12:30; Fira - Village 1

11www.escardio.org

#ESCcongress

Debating the role of inflammation in cardiovascular diseaseThe long-awaited CANTOS study, exploring treatment for cardiac inflammation, was presented in a ESC Hot Line session yesterday (see front page for the full results). The phase III study, which met its primary endpoint, is being heralded as ground-breaking because it provides the first real evidence for the inflammation hypothesis of atherosclerosis.

In the Great Debate this morning Professor Paul M Ridker (Harvard Medical School, Boston, USA), the principal investigator of

the CANTOS study, will undoubtedly be drawing heavily upon his latest results to support the motion “Inflammation plays a key role in coronary artery disease”. “The debate should be interesting to attend because we’re right at the very beginning of a para-digm shift in our core thinking about the treatment of atherosclerosis,” he told ESC Congress News.

It is part of the move towards personalised medicine, which provides the right therapy to the right patient at the right time. “We’re finding that patients with residual inflammatory risk are very common and believe that their treatment should differ from patients with residual cholesterol risk,” Prof. Ridker says.

Support for the role of inflammation in coronary artery disease (CAD) originally came from observations that up to half of all events occur in apparently healthy individuals with few traditional risk factors, including dyslipidaemia. Studies have suggested inflammation plays a key role in dest-abilisation and rupture of atherosclerotic plaques, leading to myocardial infarction (MI).

C-reactive protein (CRP), a marker of the inflammatory process, has been a forerunner in the search for inflammatory markers. In the Physician’s Health study involving 22,071 healthy middle aged men (1997) it has been shown that those in the highest quartile for CRP had three times the risk of future MI and twice the risk of future ischaemic stroke in comparison to those in the lowest quartile (NEJM 1997;336: 973-9). The findings were endorsed by the Women’s Health

study, involving 39,876 healthy postmenopausal women, which showed that those with highest levels of CRP had five times the risk of developing CVD and seven times the risk of having a heart at-tack or stroke compared to subjects with the lowest levels (JAMA 2002, 28; 288:980-7).

In the JUPITER study, it was demonstrated that rosuvastatin (a statin known to reduce both LDL cholesterol and CRP) reduced risk of MI and stroke in patients with low levels of cholesterol and high levels of CRP (N Engl J Med 2008; 359: 2195-2207). Here due to the dual effects of statins it was impossible to disentangle benefits arising from reducing cholesterol from those due to anti-inflammatory effects. This left the question of whether targeting inflammation on its own repre-sented a viable treatment for decreasing the risk of atherosclerosis unanswered.

To properly address the inflammatory hypothesis therapeutic strategies that inhibit inflammation with-out having a major effect on LDL cholesterol were needed. “A big part of the challenge has been which of many inflammatory components do we target, and how do we do it safely?” says Prof. Ridker.

CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) , which enrolled more than 10,000 patients, set out to test whether blocking the pro-inflammatory cytokine interleu-kin -1β (IL1β) with canakinumab, in comparison to placebo, reduces the rate of recurrent MI, stroke and cardiovascular death among MI patients who remain at high risk due to persistent elevation of the inflammatory biomarker CRP (≥2mg/L) despite receiving the best medical care. Canaki-numab, a human monoclonal antibody neutralising

inteleukin-1β, is already approved for use in sev-eral rare heritable paediatric conditions associated with IL-1β over expression.

For the inflammation hypothesis of cardio-vascular disease to become widely accepted, further studies will be needed to show that other anti-inflammatory agents have beneficial effects. Further support could come from the National Heart Lung and Blood Institute (NHLBI)-funded CIRT (Cardiovascular Inflammation Reduction Trial) study testing whether low-dose methotrexate

reduces MI or death in people with type 2 diabetes or metabolic syndrome that have had a MI or have stable coronary artery disease. These results, how-ever, are not anticipated for several years.

In the debate today Professor Alberico Catapano Catapano (University of Milan, Italy), an advocate of aggressive reduction of cholesterol in high-risk patients, will oppose the motion. He may cite the fate of GSK’s darapladib (an inhibitor of an en-zyme responsible for pro inflammatory mediators within the atherosclerotic plaque [lipoprotein-as-sociated phospholipase A2]). The fact that in both SOLID TIMI 52 and STABILITY, darapladib produced negative findings, serves as a reminder of the many challenges facing novel therapeutics directed towards the inflammatory cascade.

Inflammation and cardiovascular disease11:00–12:30; Dali - The Hub

“Shop till you drop” in BarcelonaThe city of Barcelona is shaped by its retail history. From midday to three or four in the afternoon, the streets are deserted as the many family-owned boutiques close for the traditional siesta. But, come back at five o’clock and Barcelona looks like a different city, as locals and tourists alike explore the tiny shops lining the streets.

Barcelona’s independent vendors of-fer everything from artisanal clothes and accessories to handmade

sweets, souvenirs and art. From Les Corts to Barri Gòtic—whatever your budget, whatever your interests—the city will have a shopping district for you. Barcelona Turisme’s “Geniune Shops” tour offers visitors the opportunity to explore the best of the city’s thriving local stores.

For high fashion, one of the city’s most famous streets—the Passeig de Gràcia—of-fers flagship luxury shops. Nestled between some of the Barcelona’s most distinctive modernist buildings, you will find Gucci and Hermès. The city’s “Shopping line” extends 5km from the Plaça de Catalunya to the winding streets of the Gràcia district.

As you cross Diagonal—a vast avinguda cleaving the city in two—you will find the high-end local boutique stores of Gràcia. These colourful shops become trendier and cheaper the further north you walk. The district provides a welcome calm after the heady and imposing Passeig de Gràcia. Fol-low its charming paths to find poster stores, camera shops, and arty local bars.

For a sensory experience like no other, the world-famous Mercado de la Boqueria off La Rambla offers a bustling, colourful array of fresh fruit, cured meats and fish. Be sure

to pick up some turrón and jamón ibérico as a souvenir for friends and family.

For a market off-the-beaten-track, Santa Catarina offers locals exquisite local delica-cies under a Gaudi-inspired rainbow roof in the Born district. Locals are fiercely proud of ensaimadas—a delicious Catalonian pastry—and of the region’s butifarra and morcilla sausages.

Returning to La Rambla, the long, bus-tling street offers a host of tourist-geared shops and market stalls. Follow it all the way to La Rambla de Mar and you will find a boardwalk of local artists selling high-quality paintings, fine art photogra-phy and, of course, on-demand caricatures for visitors. La Rambla offers souvenirs aplenty amid hostels, bars and currency exchange stores.

If you are after a more unusual souvenir, try visiting one of the three “Barcelona Original” stores at the tourist information offices. This local initiative showcases the very best of the city’s design.

In addition to the many independent shop-ping regions, international favourites like H&M and Desigual can be found on Passieg de Gràcia. Large shopping centres can also be found across the city, from L’illa Diago-nal in Les Corts to Diagonal Mar Shopping on Poblenou water.

A 1,600km journey for inherited cardiac failure

A group of nine cardiologists and fellows from the Netherlands have completed a cycling journey to ESC

in Barcelona. The five men and four women from four hospitals cycled 1,600km in eight days—they left the Netherlands on Saturday 19 August and arrived in Barcelona on Satur-day 26 August.

According to Yolande Appelman and Pieter Doevendans, it was a tough ride with about 200km each day, going through the mountains in variable weather conditions. The group started the tour to raise money for inherited cardiac failure caused by a mutation in the phospholamban (PLN) gene. The founder mutation has been identified in the Netherlands, and half of the carriers

become symptomatic requiring ICD, me-chanical support or cardiac transplantation. The cyclists were supported by the Heart Foundation of the Netherlands, PLN Foun-dation and Netherlands Heart Institute. The group has raised approximately €40,000 and is still accepting donations.

Prof. Bax with Doevendans and Appelman

BACKGROUND

www.escardio.org#ESCcongress12

ESC CONGRESS NEWSEditors-in-Chief: Stephan Achenbach, Kurt Huber, Steen Dalby Kristensen, Freek W.A. VerheugtMedical writers: Biba Medical staffCopyright ESC

Social media can make things much easier. For instance, organisations such as the ESC

can better reach delegates and help spread more information. I hope that social media will help us in our future day-to-day practice as well. In the Czech Republic, our patients are not used to interacting with physicians through social media, but this is starting to improve. Czech patients are discovering that they can use social media to interact with physicians and learn about cardiovascular health. Doctors need to use social media to connect with these patients and help spread information about cardiology.

I think that we have underestimat-ed the power of social media, in particular how it could help us to

interact with our patients. We should try to establish more direct contact; everyone goes online anyway, so why not go online and communicate with your physician? Educating patients is also an obvious use for social media, and I think we could develop much closer interactions so that we can learn what is important for our patients, directly from them.

Daniel Karpianus (Czech Republic) Signe Holm Larsen (Denmark)

What opportunities does social media create for you?

Faces in the crowdA comprehensive resource for allAn online platform, ESC Cardiovascular Medicine Online, based on the upcoming third edition of the European Society of Cardiology (ESC) Textbook of Cardiovascular Medicine, is due to be launched early next year exclusively for ESC Professional Members. With third edition available later in print, this multimedia resource will provide you with a thoroughly modern reference work.

Professor John Camm (St George’s University of London, London, UK), an Editor-in-Chief of the textbook, says

that the third edition seeks to “join everything from the ESC, from an education perspective, together”. The number of chapters, section editors, and Editors-in-Chief—800, 64, and four, respectively—is proof of just how com-prehensive this new work will be. Furthermore, the online edition will include videos as well as the figures and tables that are typically seen in a printed textbook. Professor Thomas F. Lüscher (Zurich Heart House, Careum Campus, Zurich, Switzerland), another of the Editors-in-Chief, comments: “It will be really dynamic. For example, a reader may want to find out more about giant cell myocarditis, because a patient with the condition has presented in their clinic, so they use the online platform. By watching a vid-eo, they can see what the histology looks like and what the left ventricular fraction looks like etc.”

Another important feature of the online version is that it will be regularly updated. Prof. Lüscher observes that a limitation of a print textbook is that it may become outdated—potentially, even by the time it has been printed—because of the lengthy writing, editing, and printing process. He notes that some chapters may have been written a year or two prior to a textbook coming out. Therefore, he says, the aim is to update the online version three times a year to coincide with data presented at ESC Con-gresses and other major cardiology conferences. The online platform shall, thus, be kept fresh with updates incorporating the latest data and shall also be revised to include the latest ESC Guidelines.

The online platform launches in the first quarter of 2018 and is only available to Professional

Members of the ESC. For those who prefer a more traditional textbook, the (printed) third edition of ESC Textbook of Cardiovascular Medicine will be made available for the ESC Congress 2018 in Munich.

Prof. Camm believes that both ESC Cardiovas-cular Medicine Online and the ESC Textbook of Cardiovascular Medicine are useful resources for all cardiologists—even those who are as experi-enced as himself. He says: that “no one can retain all of the information” that they receive through-out their career and, therefore, the textbook and online platform can serve as a useful reminder. Furthermore, Prof. Camm states, they can learn new things “because it [the online platform] will continuously be updated with new knowledge.”

Helen Liepman (Senior Publisher, Medicine, Oxford University Press) comments: “Oxford University Press is extremely proud to be publish-ing the new edition of this innovative project on behalf of the ESC. The publication takes a central position in the ESC publication portfolio and will have dynamic links through to primary research papers and articles especially those from the ESC journal family such as the leading European Heart Journal. In due course, the full integrated access to the dynamic digital version will be available via annual subscription and the full launch is planned for July 2018. Professional Members of the Society will be given advance access earlier in 2018 as a member benefit. The publication is being show-cased during the Congress at the OUP stand.

The other Editors-in-Chief are Professor Patrick Serruys (National Heart and Lung Institute, Impe-rial College London, London, UK) and Professor Gerald Maurer (Medical University Vienna, Vienna, Austria).