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Scientific highlights: 4th European – Middle East forum on cardiovascular risks

Scientific highlights: 4th European – Middle East forum on cardiovascular risks
  • Cardiometabolic
  • Hypertension

Resource type

Publication

Usage

Practical

4th European-Middle East forum on cardiovascular risks: treatment of hypertension with established drugs or new therapeutic approaches 

The forum on cardiovascular risks took place in Budapest, Hungary on 28th November, 2015. It was organised by Stefano Taddei (Italy) and examined recent evidence on the treatment of hypertension focussing on the correct use of old drugs such as beta-blockers and the newer therapeutic approaches, for example renal denervation. Furthermore, main hypertension – derived clinical conditions including acute coronary syndrome and heart failure, were discussed and possible solutions explored during direct interaction with participants using a clinical case.

Finally, important new cardiovascular treatments, such as new anticoagulant compounds, and special clinical conditions, such as cardiovascular risk related to vascular surgery, were also debated.

Hypertension increasing worldwide – a cause for concern

Paolo Palatini (Italy) opened the conference by describing the prevalence of hypertension, the most important cardiovascular (CV) risk factor and first cause of death in the world. Hypertension increases with aging and its prevalence is increasing in both developed and developing countries including China and Arab countries. However, environmental factors such as diet can influence the prevalence of hypertension in different populations. For example, in Bantu villagers in Tanzania both definite and borderline hypertension were significantly lower in those with a largely fish diet compared with a vegetarian diet. Differences in the risk of acute myocardial infarction associated with hypertension, smoking or abdominal obesity vary in different populations.

Interestingly, no change in average blood pressure has been observed in patients receiving antihypertensive treatments compared with untreated patients. The EUROASPIRE surveys (Czech Republic, Finland, France, Germany, Hungary, Italy, Netherlands and Slovenia) indicated that lifestyle in coronary patients is a major concern with no change in smoking and continuing adverse trends in diabetes, obesity and central obesity and no improvement in blood pressure control despite increased use of antihypertensive medications. Professor Palatini warned that prevalence of CVD is projected to increase in the coming decades, which will necessitate more aggressive management of hypertension and other risk factors.

Renal denervation – an option for resistant hypertension?

Renal denervation has been proposed as a therapeutic tool for patients with resistant hypertension, stated Guido Grassi (Italy). Overall prevalence of renal hypertension is approximately 5%. Spironolactone/eplerenone are the most effective additional drugs to treat resistant hypertension. The beneficial effect of renal denervation observed in the small initial trials was not confirmed in the large Symplicity hypertension-3 (HTN-3) trial. In this trial, the response was different in some patient subgroups, such as African Americans where there was a similar decrease in blood pressure but large decreases in control patients. However, a reanalysis of the trial results indicated that there were a number of variations in the way the procedure was performed and changes to patients’ medications and drug adherence which may have had a significant impact on the findings. Furthermore, the number of ablations has a large effect on bp reduction (the higher the number the greater the decrease in bp). Professor Grassi emphasised that future trials, with best drug therapy being the comparator rather than sham treatment and other variables carefully controlled, are needed to establish the true benefit of renal denervation.

New oral anticoagulant compounds generally have a more favourable benefit-risk profile than vitamin-K antagonists

Deidre Lane (UK) reminded the delegates that stroke is the most important CV event related to atrial fibrillation and stroke prevention is central to the modern management of nonvalvular atrial fibrilliation (NVAF). As there have been no head-to-head studies of new oral anticoagulant compounds (NOACs), conclusions cannot be made about their relative efficacy and safety. Aspirin monotherapy should not be used for stroke prevention in NVAF, for example apixaban shows a significant reduction in stroke and systemic embolism with a similar risk of bleeding.

Real-world data for dabigatran in NVAF indicated that it had greater efficacy than warfarin in patients with NVAF for stroke, intracranial haemorrhage, major bleed and GI bleed. Furthermore, all NOACs have been shown to be non-inferior to warfarin in terms of efficacy for stroke prevention in AF patients. Thus real-world data generally mirror results from clinical trials.

The most appropriate oral anticoagulant compound (OAC) should be selected based on the patient risk profile considering the patient’s preference. However, regardless of the OAC, adherence is essential to achieve optimum results and this may involve patient education. Dr Lane reiterated that it is important to regularly review patient management and optimum management is best achieved with a multi-disciplinary team.

Assessment of pre-operative risk can prevent myocardial infarction after vascular surgery

Peri-operative myocardial infarction can occur as a result of 2 distinct mechanisms – acute coronary syndrome and prolonged myocardial oxygen supply-demand inbalance, said Erland Erdmann (Germany). The risk of peri-operative complications depends on the condition of the patient before surgery, the prevalence of co morbidities and the urgency, magnitude, type and duration of the surgical procedure. Pre-operative risk assessment should include patient history, a physical examination and only if there are pathological findings, ECG, stress test and echocardiogram. In addition, pharmacological management and pre-operative revascularization are useful risk reduction strategies.

The 4 main risk markers of adverse post-operative outcome are left ventricular dysfunction, myocardial ischaemia, arrhythmia and heart valve abnormalities. Peri-operative beta blockade is only justified in high risk patients, when needed without vascular surgery and as continuation of medication. The ESC guidelines recommend peri-operative continuation of statins while pre-operative initiation of statins should be considered in patients undergoing vascular surgery. Other medications such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) should only be considered with caution and nitroglycerine is not recommended. Dr Erdmann stressed that early identification of post-operative complications decreases post-operative morbidity and mortality.

Potential new treatments and devices for heart failure

Heart failure is the final step in the CV continuum. Ranil de Silva commented that the incidence of heart failure is increasing especially with the ageing population. Pharmacologic therapy (diuretics, digoxin, ACEi and beta-blockers) improves mortality in heart failure. New therapeutic approaches have been developed for patients with heart failure and reduced ejection fraction which may improve prognosis. In particular LCZ696, a combination of sacubitril and valsartan has demonstrated significantly improved outcome in heart failure patients compared with enalapril in the PARADIGM-HF study. A reduction in symptom deterioration, need to intensify oral therapy or add iv therapy, accident and emergency attendance or hospitalisation, intensive care unit or inotropic support and sudden cardiac or heart failure death was observed with LCZ696.

There are also a number of devices that may be beneficial for patients with heart failure and reduced ejection fraction, for example, MRI conditional pacemakers and implanted cardioverter-defibrillators. Furthermore devices that remotely monitor patients can improve outcomes for heart failure patients. Dr de Silva stated that for patients with heart failure and reduced ejection fraction existing drugs including ACEi, ARBs, mineralocorticoid receptor antagonists and nitrates have no significant benefit. However, promising newer medications and other interventions are currently under investigation such as ivabradine, LCZ696, phosphodiesterase enzyme type 5 inhibitors, soluble guanylate cyclase inhibitors, renal denervation, SERCA2a gene therapy and exercise.

Clinical case

Stefano Taddei (Italy) presented a clinical case of a 73-year-old man hospitalised due to symptoms that included progressively worsening dyspnea, marked fatigue and insomnia, edema of the lower limbs, contraction of dieresis, worsening visual acuity and confused and distorted vision. He had a history of arterial hypertension, atrial fibrillation and congestive heart failure with dyspnea associated with peripheral edema and oliguria.

The delegates considered that heart disease was probably the cause of his heart failure and that further investigations should include biochemical, ECG, chest X-ray, screening for tumor markers and an echocardiogram. With respect to his treatment, the majority felt that furosemide should be changed to iv administration, irbesartan replaced with an ACE inhibitor, digoxin replaced with beta-blocker, allopurinol maintained, and nitroglycerine stopped. Thus his treatment then comprised furosemide, enalapril, bisoprolol, allopurinol and warfarin. After monitoring his subsequent progress warfarin was withdrawn with apixabant and spironolactone added. He was discharged from hospital with atrial fibrillation at average frequency of ventricular response, marked alterations in ventricular repolarisation and sporadic ventricular extrasystoles and his initial congestion was resolved.

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Regional conference
Budapest, Hungary
Nov 28, 2015
Target audience
Cardiologists, internists
EBAC
by Excemed
Cardiometabolic