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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016
392
AFRICA
European Society of Cardiology congress update,
Rome, 27–31 August 2016
The annual European Society of Cardiology (ESC) meeting was
held at the Nuova Fiera di Roma with over 32 000 delegates from
126 countries in attendance.
The meeting commenced with an outstanding address on the
heart and art by a British cardiac surgeon, who demonstrated
the amazing discoveries in cardiac anatomy and function made
by Leonardo da Vinci over 500 years ago, and the awarding of
the ESC gold medal to Dr Bernard Gersh of the Mayo Clinic,
whose foundational training in cardiology took place at Groote
Schuur Hospital.
Four new ESC guidelines addressing atrial fibrillation
(AF), heart failure, cardiovascular (CV) disease prevention
and dyslipidaemia, as well as a position paper on cardio-
oncology, were released during the meeting. The full texts of
these documents are available to all at
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines.
The meeting planners placed particular emphasis on the
‘heart team’ approach and included a large number of ‘heart
hub’ presentations. The latter were delivered ‘in the round’ and
provided a more informal, more easily accessible presentation
format, which improved interaction between presenters and the
audience.
The following are my impressions of the presentations I
attended over the five days of the meeting.
Dyslipidaemia
The 2016 dyslipidaemia guideline has been harmonised with the
CV disease prevention guideline, which appeared simultaneously.
The ESC has maintained the SCORE risk factor charts as well
as a chart estimating
relative
risk in younger people. The risk
categories have likewise been maintained. However, whereas the
presence of significant plaque on carotid ultrasound classifies
the patient as very high risk, increased carotid intima–media
thickness does not. Treatment targets have been maintained.
Very high-risk patients have a low-density lipoprotein cholesterol
(LDL-C) target of
<
1.8 mmol/l, high-risk subjects
<
2.6 mmol/l
and moderate- to low-risk individuals
<
3.0 mmol/l. In patients
with diabetes an HbA
1c
<
7% is recommended in addition. In
very high- and high-risk patients, treatment should achieve a
>
50% reduction in LDL-C. High-density lipoprotein cholesterol
(HDL-C), apoB/apoA1 and non-HDL-C/HDL-C ratios are
not recommended as treatment targets. Statins remain first-line
treatment, given up to the highest recommended dose or highest
tolerable dose to achieve the treatment goal. Statin treatment
should be given for the same indications and using the same
targets in women and the elderly.
A small Japanese study from the Heart Institute of Japan
involving 1 734 patients with dyslipidaemia followed for 3.9 years
after acute coronary syndrome (ACS) found no benefit from
the addition of ezetimibe to pitivastatin vs pitivastatin alone.
LDL-C was 1.7 mmol/l in the combination group vs 2.2 mmol/l
in the statin-only group.
Patients with heterozygous familial hypercholesterolaemia
(FH) respond inadequately to statin therapy and frequently
require plasma apheresis to lower their LDL-C. Apheresis is both
expensive and inconvenient for the patient. A study evaluating
the PCSK9 inhibitor, alirocumab, demonstrated a 75% reduction
in the need for apheresis.
1
Unfortunately many patients were not
taking statins during the study, so the effect of the combination
of PCSK9 inhibition, statin therapy and apheresis could not be
determined (Table 1).
Hypertension
A session on hypertension dealt with the problems of masked
and white-coat hypertension (WCH). Masked hypertension is
defined as a normal office blood pressure, but elevated home
blood pressure or 24-hour ambulatory blood pressure readings.
Home monitoring (generally recorded at rest) and ambulatory
blood pressure (recorded over 24 hours) measure different
aspects of the blood pressure profile. Masked-hypertension
patients are, by definition, untreated. Masked uncontrolled
hypertension (MUCH) is seen in treated hypertensives. The
blood pressure typically fluctuates and elevations may occur
either during waking hours or at night (typically in obstructive
sleep apnoea). Masked hypertension is present in 10–20% of the
population and doubles the risk of a CV event.
There is currently no guidance from clinical trials as to the
correct treatment of masked hypertension. The MASTERS
trial commenced recently to explore what the correct treatment
should be. At present the recommendation is to establish strict
risk factor control and, though ‘logically’ incorrect, not to
institute antihypertensive therapy.
Table 1. ESC CP guidelines 2016: dyslipidaemia
Treatment targets
2011 ESC dyslipidaemia guidelines
2016 ESC dyslipidaemia guidelines
Recommendation
Class Level Recommendation
Class Level
Very-high CV risk:
LDL-C goal < 70 mg/dl
(1.8 mmol/l) and/or 50%
reduction when target
cannot be reached
I
A Very-high CV risk:
LDL-C goal < 70 mg/dl (1.8
mmol/l) and/or 50% reduc-
tion if baseline is 70–135
mg/dl (1.8–3.5 mmol/l)
I
B
High CV risk:
LDL-C goal < 100 mg/l
(2.5 mmol/l)
IIa A High CV risk:
LDL-C goal < 100 mg/l (2.6
mmol/l) or 50% reduction
if baseline is 100–200 mg/dl
(2.6–5.1 mmol/l)
I
B
Moderate CV risk:
LDL-C goal < 115 mg/l
(3.0 mmol/l)
IIa C Moderate CV risk:
LDL-C goal < 115 mg/l (3.0
mmol/l)
IIa C
Congress Report