Day 3

Monday 28 August 2017

CANTOS results show anti-inflammatory

p3 CASTLE-AF results
therapy lowers future cardiovascular events,
p5 Andreas Grüntzig’s legacy
reduces cancer incidence and mortality
Yesterday’s ESC Hot Line: Late Breaking Clinical Trials I Session marked a historic turning point in cardiology with a host p8 ESC Journal Family
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 was simultaneously published in The Lancet.
inflammation. These data, that were the first to test the inflammatory hypothesis of atherothrombosis, could signal a CANTOS results revealed that at 48 months there was an average re-
paradigm shift in the core thinking about the treatment of atherosclerosis as they provide evidence that inflammation has duction from baseline of CRP level in all groups receiving canakinumab
a causal role in cardiovascular events. Additional exploratory analyses of the trial data examined whether anti-inflamma- in comparison to the group receiving placebo. The drug did not reduce
tory therapy with canakinumab could change the occurrence of cancer and found that targeting the interleukin-1ß innate lipid levels from baseline. Results revealed that at a median follow-up
immunity pathway significantly reduced cancer incidence and mortality, particularly for lung cancer.

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anakinumab 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 Dr. Paul M Ridker
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
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
Continued on page 2

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.
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.
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

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OMPASS 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) Dr. John Eikelboom
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
The researchers randomly assigned participants Continued on page 3
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

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#ESCcongress 1
Latest PCI research in the spotlight
In 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 patients
Doctor 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 Dr. Ben He
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 therapy
In 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 Dr. Cannon
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 rate
New 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 Dr. Fournier
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.”

CANTOS results show...
Continued from page 1
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.
RACE to the top: Risk factor-driven upstream therapy
results in superior sinus rhythm management
Risk-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).

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.”
“Y
ou all know that titrated to the highest tolerated dosage and left atrial volume. Prof. Van Gelder said,
maintenance of except for statins, which were “Therapy including treatment of risk factors
sinus rhythm given at the recommended dosage. and lifestyle is effective and feasible to improve
improves AF-related symptoms. Target blood pressure was set at the maintenance of sinus rhythm in patients
However, sinus maintenance <120/80mmHg. with early persistent atrial fibrillation and heart
is cumbersome due to atrial The upstream group took part failure.” The RACE 3 results were favoura-
remodelling.” Prof. Van Gelder in a cardiac rehabilitation ble to the impact of upstream therapy on the
told the audience. “Risk-fac- Prof. Van Gelder programme, consisting of super- reduction of risk factors, instead of its effect on
tor driven upstream therapy vised exercise—which began atrial remodelling, she explained, concluding
refers to interventions that aim to modify the immediately following inclusion and before that “RACE 3 may contribute to the shift in
atrial substrate and, at the same time, have a cardioversion—and tailored counselling every focus on risk factor modification to improve
favourable effect on risk factors and diseases six weeks to stimulate sports performance. Pa- outcomes in AF patients.”
underlying AF.” tients took part in supervised physical activity “In the last few years, we have devoted a lot
In the prospective, open-label, multicentre two to three times per week for between nine of effort to the symptoms and consequences
trial, patients with early symptomatic persistent and 11 weeks. Sports were encouraged for at of AF,” discussant reviewer, Professor Josep
AF and/or HF were randomised to either least half an hour, five times per week, as well Brugada Terradellas, Hospital Clinic Barcelona,
upstream or conventional therapy groups, as medication compliance. In addition, par- Barcelona, Spain, stated. “But clearly we have
stratified by percentage of left ventricle ejection ticipants were limited to <7.5g sodium intake failed in controlling the epidemic of AF in our
fraction. The primary endpoint of the study was per day, calorie intake reduction if they had a society.” Casting a critical eye towards the study,
the presence of sinus rhythm during at least body mass index (BMI) ≥27kg/m2, and fluid Prof. Brugada Terradellas noted that RACE 3
six-sevenths of accessible time, according to restriction depending on the severity of heart was limited by its failure to account for factors
seven-day Holter monitoring at one year. failure. At one year, 75% of the upstream group known to be associated with AF, including
One-hundred and nineteen patients were as- achieved sinus rhythm, compared with 63% alcohol intake and sleep apnoea. He stated his
signed to receive risk-factor upstream therapy of the conventional group, resulting in an odds surprise that even the control group achieved
and 126 to undergo conventional therapy. Both ratio of 1.765 with a lower 95% confidence 63% sinus rhythm, and—noting the “dual
groups received standard care for AF and HF interval of 1.115 and a p-value of 0.021. epidemic” of obesity and AF—he expressed
according to the present guidelines. All par- Looking at secondary endpoints, Prof. Van regret that BMI results were not improved in
ticipants received cardioversion therapy three Gelder said, “Blood pressure reduction was the upstream group. In spite of these limitations,
weeks after inclusion in the study. The mean significantly larger in the upstream group, and he praised the study, telling the audience that it
age was 65 years and 80% of participants were the same was true for N-terminal pro b-type “opens the door” to future research which may
men. Risk factor-driven therapies were initiated natriuretic peptide.” Both groups saw a similar demonstrate that aggressive therapy can reduce
in the upstream group: mineralocorticoid increase in ejection fraction, while low density the number of patients with AF. “If we are more
receptor antagonist, statins, ACE-inhibitors lipid reduction was significantly higher in the aggressive,” he concluded, “we might find a
and/or angiotensin-receptor blockers as well as upstream group. No changes or differences preventative therapy and maybe, in the future,
cardiac rehabilitation. All medical therapy was between the groups were observed in BMI we will reduce the burden of AF.”

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#ESCcongress
Catheter ablation of atrial fibrillation
shown to reduce mortality and
hospitalisations in heart failure patients
Catheter 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.
“T
he 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
Dr. Nassir Marrouche
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.”
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Will COMPASS point...
Continued from page 1
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).
Bleeding
Major 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-PAD
Data 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%.
3
ESC Guidelines add “S” to
peripheral arterial disease to
bring greater clarity
T
he 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,
4
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”.
www.escardio.org
#ESCcongress
Valvular Heart Disease Guidelines
emphasise Heart Team decisions
T
he 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 Disease
08.30–10:00; Barcelona - Main
Auditorium
40 years of angioplasty, and the man who made it possible
This 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.
I
n 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
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
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,
www.escardio.org
5
#ESCcongress
New interactive session to Abstract of the day: Study confirms
explore different PCI strategies prior infective endocarditis carries
A new type of session—Let’s Talk about Strategy—launches at ESC Congress
greatest risk of the condition
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 Results from a Danish study support both European and US guidelines by finding
and why they decide in a certain way. In keeping with this year’s Spotlight on that people with a history of infective endocarditis have a significantly greater
risk of developing the condition than the general population.

I
40 years of percutaneous coronary intervention (PCI), the session will focus on
different PCI cases ranging from the simple to the more complex. nvestigators Doctor Lauge Ostergaard among these “high-risk” groups and compare

E
(Rigshospitalet – Copenhagen University this incidence with that of gender-matched
SC Congress Programme Committee Chairperson, Professor Hospital, The Heart Centre, Copenhagen, controls. Of 24,253 patients, 5,192 had prior
Stephan Achenbach (Department of Cardiology, Friedrich Denmark) and others observe that both Euro- endocarditis, 17,241 had a prosthetic heart
Alexander Universität Erlangen-Nürnberg, Erlangen, Germa- pean and US guidelines state that patients with valve, and 1,820 had cyanotic congenital heart
ny)—who is moderating the session with Professor Spencer King prior infective endocarditis, a prosthetic heart disease. The authors report: “The cumulative
(Emory Heart Center at Saint Joseph’s Hospital, Atlanta, USA)—ex- valve or cyanotic congenital heart disease are risk of infective endocarditis over 10 years
plains: “The moderators will show a coronary angiogram and will ask all at increased risk of developing infective was 10.4% for prior endocarditis, 3.4% for a
the panellists in turn how they would treat the lesion that is shown.” endocarditis. However, in their abstract, they prosthetic heart valve, and 1.1% for those with
Come to today’s session to see He adds that what will be interesting is to see if the panellists agree note: “Knowledge is sparse on the relative cyanotic congenital heart disease. All groups
how a panel of PCI experts about how the lesion should be treated, commenting: “Experts do not risk between these three groups and compared carried a significant higher risk of infective
will treat this case
always agree and can often have different opinions from each other”. with controls”.Therefore, using data from endocarditis than matched controls from the
The experts will not only discuss how they would manage a case but will also explore why they would Danish nationwide registries, they sought to general population. These findings justify the
manage it in a particular way. “It is always good to hear and understand the reasons behind choosing a par- identify the incidence of infective endocarditis European and American guidelines.”
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- Let’s Talk about Strategy - Interventional
sor Helge Möllmann (Department approaches from easy to complex anatomy
of Cardiology, Johannes Hospital,
14:00–15:30; Spotlight Stage
Dortmund, Germany).

www.escardio.org
6
#ESCcongress
Where next for PCI versus CABG? Imaging quiz: What’s
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
your diagnosis?
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? BROUGHT TO YOU BY THE EUROPEAN
Professor Michael Haude (Medical Clinic I Lukas Hospital, Neuss, Germany) explores recent evidence ASSOCIATION OF CARDIOVASCULAR

S
regarding the use of of PCI versus coronary artery bypass grafting (CABG) for coronary revascularisation. IMAGING (EACVI)

YNTAX 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 Three-dimensional CT angiography of the
scaffolds still have thepotential to improve on existing devic- heart in a 53-year-old patient with shortness
es and even possibly be equivalent to surgery. He comments: of breath.
“There is still hope with the improved technology of the
second-generation devices [there have been some limitations Stephan Achenbach, Friedrich-Alexander
with the first-generation devices]. But, these newer devices University Erlangen-Nürnberg, Germany.
have to be compared in randomised controlled trials against
current drug-eluting stents to show that they, at least, are See page 9 for solution.
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).

www.escardio.org
7
#ESCcongress
Sports cardiology: The conundrum of
distinguishing physiological adaptations
I S
n an interactive
session yesterday,
leading sports
cardiologists
discussed the
“conundrums”
facing clinicians
screening athletes in
Prof. Antonio Pelliccia 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
The ESC Journal Family is breaking new ground
The 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.
P
rofessor 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
8
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.
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
www.escardio.org
#ESCcongress
Could SPRINT change BP management in
elderly patients?
PRINT (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
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
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 Dr. Luis Miguel Ruilope
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.”
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.
“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 outcomes that could be prevented if you the risk of stroke is high enough to war- systemic embolism, and death), of strat-
the AF-SCREEN International Collaboration—a consortium that find it in time and then do something rant treatment. A screening programme egies for screening that will strengthen
seeks to promote the case for screening for atrial fibrillation about it.” could be part of a routine health check the evidence base to inform guidelines
(AF). ESC Congress News reviews the arguments for AF screening AF-SCREEN’s White Paper calls or chronic care assessment, particu- and national systematic screening
and looks at the work of AF-SCREEN, specifically its White for screening programmes—aimed at larly in the over 65 year olds. Routine programmes.
Paper recently published in Circulation. people ≥65 years of age—that could use checks like these start at age 65 in many The White Paper’s publication

P
rofessor 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
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,
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,
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 4
29 August
08:30–10:00: 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).

www.escardio.org
9
#ESCcongress
 Find the right balance of antithrombotic therapy in PCI
Antithrombotic treatment for patients during and after they undergo percutaneous coronary intervention In 2014, the DAPT study (published in NEJM) of 99 61
(PCI) has been the subject of much debate and uncertainty. This overview looks at the current status patients demonstrated that extending DAPT beyond one year after
of antithrombotic therapy in this context, and examines data from recent trials and their impact on the placement of a DES significantly reduced the risks of stent
treatment options. thrombosis and major adverse cardiovascular and cerebrovascular

E “
xisting 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
Prof. Gilles Montalescot 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
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.”
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.
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.
State of the art in platelet biology
11:00–12:30; Fira - Village 1

The ESC is a proud partner in the Get the Barça experience

development of biomedical code of ethics
T D
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 Camp Nou
At the ESC, we believe that by
working together with other scientific elegates looking to sample the museum that is one of the most visited
societies, science will have a stronger delights of Barcelona would in Europe; it is open every day of
voice to promote the best possible be well advised to take in a the year apart from 1 January and 25
medical and scientific practices visit to the iconic Camp Nou, stadium December. With tickets available from
around Europe.” for the city’s eponymous football €20, the tour lasts from 1.5 to two
He continues: “The Alliance is team, FC Barcelona. hours and allows visitors to experience
committed to promoting excellence One of Europe’s largest, the stadi- the thrill of walking out onto the Camp
in European biomedical research and um is home to some of the world’s Nou pitch, exploring the Messi area,
innovation, with the goal of improv- most expensive and celebrated and marvelling at the five European
ing the health and wellbeing of all footballers. But Camp Nou (“new cups won by the team, as well as the
European citizens. Its member organ- place” in Catalan) is more than just many domestic trophies.
isations offer essential, fair, balanced, a football stadium. It has played an FC Barcelona is currently placed
and unbiased continuing professional integral part in the city’s history and second in La Liga, the Spanish football
education; diagnostic and treatment development, and is held in high league, behind their rivals Real Madrid.
guidelines to ensure the highest regard by Catalonians. For more information, see: www.
scientific and medical standards; and The stadium boasts a tour, and a fcbarcelona.com/tour/buy-tickets
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/

www.escardio.org
10
#ESCcongress
 BACKGROUND

Debating the role of inflammation in 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-

cardiovascular disease ever, are not anticipated for several years.

In the debate today Professor Alberico Catapano
Catapano (University of Milan, Italy), an advocate
The long-awaited CANTOS study, exploring treatment for cardiac inflammation, was presented in a ESC Hot Line session of aggressive reduction of cholesterol in high-risk
yesterday (see front page for the full results). The phase III study, which met its primary endpoint, is being heralded as ground- patients, will oppose the motion. He may cite the
breaking because it provides the first real evidence for the inflammation hypothesis of atherosclerosis. fate of GSK’s darapladib (an inhibitor of an en-

I
n 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,”
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-
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
A 1,600km journey for
inherited cardiac failure
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 disease
11:00–12:30; Dali - The Hub

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
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
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 Prof. Bax with Doevendans and Appelman
Pieter Doevendans, it was a tough ride with
about 200km each day, going through the become symptomatic requiring ICD, me-
mountains in variable weather conditions. chanical support or cardiac transplantation.
The group started the tour to raise money The cyclists were supported by the Heart
for inherited cardiac failure caused by a Foundation of the Netherlands, PLN Foun-
mutation in the phospholamban (PLN) gene. dation and Netherlands Heart Institute. The
The founder mutation has been identified group has raised approximately €40,000 and
in the Netherlands, and half of the carriers is still accepting donations.

“Shop till you drop” in

Barcelona
The 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.

B
arcelona’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.

www.escardio.org
11
#ESCcongress
A comprehensive resource for all
An 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.
P
rofessor 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
12
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).
www.escardio.org
#ESCcongress
Faces in the crowd
What opportunities does
social media create for you?
Daniel Karpianus (Czech Republic) Signe Holm Larsen (Denmark)
S I
ocial media can make things think that we have underestimat-
much easier. For instance, ed the power of social media, in
organisations such as the ESC particular how it could help us to
can better reach delegates and help interact with our patients. We should
spread more information. I hope that try to establish more direct contact;
social media will help us in our future everyone goes online anyway, so why
day-to-day practice as well. In the not go online and communicate with
Czech Republic, our patients are not your physician? Educating patients
used to interacting with physicians is also an obvious use for social
through social media, but this is media, and I think we could develop
starting to improve. Czech patients are much closer interactions so that we
discovering that they can use social can learn what is important for our
media to interact with physicians and patients, directly from them.
learn about cardiovascular health.
Doctors need to use social media to
connect with these patients and help
spread information about cardiology.
ESC CONGRESS NEWS
Editors-in-Chief: Stephan Achenbach, Kurt Huber, Steen Dalby
Kristensen, Freek W.A. Verheugt
Medical writers: Biba Medical staff
Copyright ESC