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Congress Report: Scientific Highlights of the European Society of Cardiology Congress

Congress Report: Scientific Highlights of the European Society of Cardiology Congress
  • Cardiometabolic
  • Hypertension

Usage

Practical

Fiera Di Roma, Rome, Italy.  August 27–31, 2016

Hot topics at this meeting included ideal blood pressure targets after the SPRINT trial, new tools for the evaluation of blood pressure, novel devices for interventional treatment of hypertension and hypertension in women

Blood pressure targets after the SPRINT trial

Among the broad range of topics presented at the European Society of Cardiology (ESC) meeting, much attention was centered on cardiovascular disease (CVD) prevention. Indeed, the 2016 ESC guidelines for CVD prevention1 had just been released, and were presented and extensively commented on during this meeting.

Blood pressure (BP) targets have not been modified in these guidelines. However, there was a large debate after publication of the SPRINT trial2 (a randomized trial of intensive versus standard BP control), which was reflected in the session, ‘should guidelines have lowered BP targets after the SPRINT trial?’ which took place in the Gladiator’s Arena at this meeting. One of the SPRINT investigators, WC Cushman (Memphis, USA), supported this notion, while SE Kieldsen (Oslo, Norway) argued against. Other speakers, including R Dusing (Bonn, Germany) and J Redon (Valencia, Spain) addressed probably the hottest topic in hypertension at the 2016 ESC meeting: ‘how could emerging clinical evidence impact future BP guidelines?’ The SPRINT trial clearly demonstrates the cardiovascular benefits of aiming at a lower target BP (<120/80 mmHg) instead of the classic 140/90 mmHg for high-risk patients without diabetes. However, it is important to highlight that in the SPRINT trial, BP was measured by a technique that has never been used before in a randomized clinical trial. Unattended office BP, obtained with automatic devices that measure BP in the absence of health professionals, is not comparable to ‘classic’ office BP measurement. It corresponds to roughly 10 mmHg less than standard office BP and has a dramatically reduced variability compared with office BP measurements by physicians or nurses. Thus, the 120 mmHg cut-off cannot automatically be translated into clinical practice and into the next edition of guidelines. Indeed, a more intensive BP-lowering treatment could be dangerous, at least in patients with stable coronary artery disease.

New tools in the evaluation of BP

Technological advances in BP measurement was covered in an exciting ‘Advances in Science’ session. ML Muiesan (Brescia, Italy) described how hypertensive emergencies in the acute setting could be diagnosed by the use of a commercially available smartphone device for the evaluation of fundus oculi. In the same session, TG Papaioannou (Athens, Greece) revealed the results of a meta-analysis of invasive validation studies to investigate the accuracy of commercial devices and methods for non-invasive estimation of aortic systolic BP.3 Central BP is more accurate in predicting cardiovascular risk than brachial BP, and its measurement will be available increasingly in clinical practice, but the validity of the numbers obtained is crucial. The meta-analysis of 22 studies included 11 different commercial BP-reading devices and 808 patients undergoing catheterization for direct measurement of aortic BP. It showed a great discrepancy in methodologies, validation protocols and study populations. Overall, the estimation of aortic SBP by the available devices is very accurate, but only when the device is calibrated by invasive intra-arterially BP values.

The future direction of research in BP measurement tools and technologies was highlighted by F Mahfoud (Homburg/Saar, Germany). Mobile Health (m-health) will play an increasingly important role in the management of hypertensive patients. New biomedical technologies can monitor heart rate, BP, activity levels and various other indices of ‘health’, in addition to providing medication adherence alerts, and enabling a more fruitful communication with healthcare providers. Home BP telemonitoring by mobile apps and the possibility of cuffless BP measurements are in the pipeline. Cuffless devices include apps that work by application of a finger to the touch screen of a smartphone. Although these apps are among the highest rated for BP, they are highly inaccurate and thus lead to fatal errors in the management of hypertensive patients.

Novel devices for interventional treatment of hypertension

Two novel devices for interventional autonomic regulation of BP were presented in a further ‘Advances in Science’ session.

  1. W Spiering (Utrecht, Netherlands) presented a first-in-men, multicenter, non-randomized, industry-funded study assessing the safety and efficacy of a novel type of carotid stent, implanted by a percutaneous femoral approach. The self-expanding rectangular cuboid implant (MobiusHD) is designed to increase carotid sinus arterial wall strain without impacting pulsatility or laminar flow. The geometric changes of the carotid sinus enhance baroreceptor sensitivity thus decreasing sympathetic activity and lowering BP. Among the 31 patients studied, 21 reached 180-day follow-up and experienced a marked reduction in both office and 24-hour BP.
  2. P Neuzil (Prague, Czech Republic) proposed a novel therapeutic opportunity for patients with uncontrolled BP requiring a pacemaker for any cardiac indication. This therapy is an algorithm embedded in a standard dual chamber pacemaker with regular transvenous leads and implant procedure. The algorithm delivers a sequence of alternating shorter and longer AV intervals and is able to reduce ventricular filling and modulate the baroreflex response, thus reducing BP. The 27 patients with resistant hypertension enrolled to trial this algorithm experienced a reduction of about 10 mmHg in their 24-hour SBP, with no significant change in global cardiac function or left ventricular ejection fraction at 4 month follow-up. However, any long-term effects of this therapy on cardiac function are unknown.

For both treatments, randomized, placebo-controlled trials have been planned. To date, these approaches represent promising, futuristic strategies, needing extensive validation before application to clinical practice.

Hypertension in women

Gender differences in cardiovascular disease was extensively discussed at ESC 2016, including a session dedicated to hypertension in women. V Regitz-Zagrosek (Berlin, Germany) provided an excellent current overview. Interestingly, older, population-based studies suggested less control of hypertension in women, but recent global data found an equal or even better awareness, treatment and control of hypertension in women than in men. Meanwhile, there is a worrying trend towards low treatment and control in men in low income countries.

AHEM Maas (Nijmegen, The Netherlands) highlighted the fact that there are few evidence-based studies on the pathophysiology and management of female-specific risk factors for hypertension, such as pregnancy-related hypertension. Furthermore, gender differences in cardiac and vascular structure and function are still overlooked and may greatly impact cardiovascular prognosis. E Gerdts (Bergen, Norway) spoke about this as being implicated in the genesis of heart failure with preserved ejection fraction. With regards to drug treatment in hypertensive women, T Kahan (Stockholm, Sweden) showed that current evidence suggests that men and women achieve similar BP reduction with treatment, have similar benefits with treatment, and should reach similar target BP values with similar drug classes. However, analysis of data from large registries reveals that different BP-lowering drugs are used in men and women, with possible consequences on outcomes. Drug selection might be improved if more consideration were made to side effects and comorbidities in men and women. Furthermore, BP control is influenced by the sex of the patient and physician – this subtle psychosocial aspect may play a significant role and should also be taken into account to improve BP control in both men and women.


References

2016 CVD prevention summary in general practice. Available from: https://www.escardio.org/Guidelines. Accessed September 2016.
 The SPRINT Research Group. N Engl J Med 2015;373:2103–16.
Papaioannou TG, et al. J Hypertens 2016;34:1237–48.

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