european society of cardiology congress 2010

European Society of Cardiology Congress 201028 August – 1 September 2010; Stockholm, Sweden

Mary Ellen Kitler

Associates for Business and Research, Rolle, Switzerland

The mission of the European Society of Cardiology (ESC) is

to reduce the burden of cardiovascular disease in Europe. The

62 000 cardiology professionals who are members of the ESC

are based mainly in Europe. In reality, the ESC has become a

global organization with members from around the world.

The ESC Congress is a conference and event on a staggering

scale. Wholly organized by the society itself, the typical high-

lights include:

� 30 000 participants from around the world, of which 25 000

will be physicians;

� 9511 abstracts from 92 countries with 4167 (44%) accepted;[1]

� 900 hours of science and education covering a wide range of

cardiology-related topics;

� 250 breakout sessions and workshops reflecting specialty

subjects;

� 25 000m2 of exhibition space to showcase industry products

and services.

The ESC is a truly global forum in cardiology with partici-

pants from all corners of the world.

1. European Heart for Children

In 2009, the European Heart for Children (EHC) was

launched as a humanitarian effort of the ESC. The idea behind

the EHC was that access to appropriate care for children born

with congenital heart disease was not the same in all 52 coun-

tries whose national cardiac societies are members of the ESC.

At the opening session, ESCPresidentProfessorRoberto Ferrari,

Chair,Department ofCardiology,University ofFerrara, Ferrara,

Italy, stated that the EHC Foundation is now legally separate

from the ESC and is now a totally independent humanitarian

effort. The independence of EHC was made possible by do-

nations from the ESC board and ESC delegates who attended

the previous ESC congress. Leading cardiologists have parti-

cipated in two missions to Syria, one to Morocco and one to

Egypt. As a result of these four missions, there have been, in

total, more than 350 children examined, resulting in 38 opera-

tions and six referrals to Italy for complex surgery. Siemens,

Spain and Basildon Hospital, UK donated three echocardio-

graphy machines to Morocco, Kosovo and Egypt. The EHC

missions are conducted in close cooperation with three existing

organizations with a long history of good local networks. The

ESC will begin to award training grants to Moroccan health-

care professionals for training in paediatric cardiology at European

centres of excellence. Profits from sales of the newly released

‘European Cook Book’ will be donated to the EHC. Professor

Ferrari explained that h1500 is sufficient to operate on one child

with a 1-year follow-up. Professor Ferrari asked all ‘‘to give

generously’’ to EHC.

2. Cardiology Guidelines

Over the years, the ESC has developed guidelines for the

treatment of many different problems in cardiovascular medi-

cine. As new information becomes available, the guidelines are

revised to include the new information. Guidelines present man-

agement recommendations based on all the relevant evidence

on a particular subject. Numerous studies have demonstrated

that patient outcomes improve when guideline recommenda-

tions, based on the rigorous assessment of evidence based re-

search, are applied in clinical practice. The ESC has issued a

2010 compendium of abridged ESC guidelines.[2] Four new

ESC guidelines were presented at the 2010 ESC Congress, i.e.

management of grown-up congenital heart disease,[3] myocar-

dial revascularization,[4] management of atrial fibrillation[5] and

focused updates on cardiac pacing and cardiac resynchroniza-

tion therapy in heart failure.[6]

3. Advances in Atherothrombosis Research

Dr Deepak L. Bhatt, Chief of Cardiology, Veterans Affairs

Boston Healthcare System and Associate Professor of Medicine,

Harvard Medical School, Boston, MA, USA, reported on the

4-year follow-up study of participants in the international

Reduction ofAtherothrombosis for ContinuedHealth (REACH)

MEETING REPORTPharm Med 2010; 24 (5): 295-3001178-2595/10/0005-0295/$49.95/0

ª 2010 Adis Data Information BV. All rights reserved.

registry. The analysis demonstrated that there are simple clin-

ical predictors of future ischaemic events in patients at various

stages of atherothrombosis. The evaluation will assist researchers

and clinicians to design novel preventive therapies for high-risk

populations. Furthermore, the identification of high-risk popu-

lations can help to plan future clinical trials to evaluate treat-

ment options in those patients requiring the most intensive

preventive medications. The follow-up evaluation of REACH

analysed data gathered at baseline from 45 227 patients from

3647 centres in 29 countries. The primary endpoints of the 4-year

analysis were rates of cardiovascular death, myocardial infarc-

tion and stroke. A total of 34 436 patients with baseline data

were available for analysis at the 4-year follow-up. Among

patients with atherothrombosis, those with a history of ischaemic

events at baseline had the highest risk of subsequent ischaemic

events. Among all categories of patients, diabetes mellitus

substantially increased the risk of future ischaemic events. In

patients with established atherothrombosis, the presence of

polyvascular disease was a strong independent factor to predict

future ischaemic events. In patients with multiple risk factors

for atherothrombosis or established atherothrombotic disease,

the study demonstrated that four clinical criteria can be used to

identify patients at increased risk for cardiovascular events, i.e.

polyvascular disease, recent ischaemic event (less than 1 year),

prior ischaemic event at any time and diabetes. Thus, the clin-

ical trial director should consider these clinical criteria when

designing the protocol for a clinical trial to evaluate the effect of

a medication on atherothrombosis.

Dr Felicita Andreotti, Department of Cardiovascular Medi-

cine, Catholic University Medical School, Rome, Italy, the

discussant to the presentation of Dr Bhatt, stated that the

REACH registry followed a previously neglected and elusive

population, i.e. outpatients with stabilized prior stroke or myo-

cardial infarction or with stable peripheral, coronary or carotid

artery disease. She emphasized that REACH is the first long-

term registry aimed at identifying predictors of hard endpoints

in stabilized or stable patients with different manifestations of

cardiovascular disease. An important feature ofREACH is that

35% of the participants in the study were female.

4. Alpha Omega Trial

Professor Daan Kromhout, Professor of Public Health Re-

search, Division of Human Nutrition, Wageningen University,

the Netherlands, reported on the Alpha Omega Trial, an in-

vestigator-initiated study that evaluated the effect of low doses

of n-3 fatty acids on cardiovascular diseases in post-myocardial

infarction patients. The hypothesis was that n-3 fatty acids re-

duce the risk of major cardiovascular events, fatal coronary

heart disease and ventricular arrhythmia-related events. The

Alpha Omega Trial is registered with ClinicalTrials.gov, Iden-

tifier NCT00127452. The 40-month study was conducted in

32 hospitals in the Netherlands. Participants, aged 60–80 years,

used 20 grams ofmargarine spreads daily that contained the n-3

fatty acids or margarine spreads with no n-3 fatty acids. The

margarines were similar in taste, texture and colour. The cohort

included 3783 (78%) men and 1054 (22%) women. Diabetes was

present in 1014 (21%) patients; the prevalence of overweight

patients was 53% and obese 24%.

The trial group concluded that generally, low doses of n-3

fatty acids do not reduce major cardiovascular events. How-

ever, in women, a-linolenic acid (ALA) reduced major cardio-

vascular events and almost reached statistical significance

(p = 0.07); these results in women must be studied further. Pa-

tients with diabetes (n = 1014) had a 30% higher risk of major

cardiovascular events than non-diabetic patients (n = 3823). Inthe exploratory analysis of diabetic patients, n-3 fatty acids re-

duced ventricular arrhythmia-related events. ProfessorKromhout

emphasized that this result in diabetic patients must be studied

further. Professor Kromhout also noted that the reduction in

the overall rate of cardiovascular events was only half of that

expected, probably because of the excellent care that all patients

were receiving during the post-myocardial infarction phase.

That excellent care may also be why the rate of major cardio-

vascular events during the follow-up trial was no lower in the

fatty acid groups than in the placebo group. Perhaps, in the

future, pharmaceutical manufacturers will synthesize derivatives

of ALA that can reduce major cardiovascular events in women.

Professor Luigi Tavazzi, Professor of Cardiology, Gruppo

Villa Maria Care and Research, Villa Maria Cecilia Hospital,

Cotignola, Italy, the discussant to the presentation of Professor

Kromhout, congratulated the Alpha Omega Trial Group for

conducting such an independent, large-scale clinical trial with

limited governmental funds. Professor Tavazzi stated that in

particular, the food-based nature of the trial should be com-

mended as an attempt to evaluate widespread commercial ad-

vertising using sound scientific principles. Professor Tavazzi

wondered if the doses of the n-3 fatty acids were too low to be

able to show an effect in this clinical trial.

5. Coffee Consumption and Aortic Dispensability

Even before the founding of Starbucks, coffee consumption

was common throughout the world. In 2009, researchers from

the University of Athens conducted a study of the effect

of coffee consumption on the Greek Island of Ikaria. The

296 Kitler

ª 2010 Adis Data Information BV. All rights reserved. Pharm Med 2010; 24 (5)

investigators chose Ikaria because the population has a long

life expectancy and the number of residents over 90 years old

is unusually high. Dr Christina Chrysohoou, First Cardiology

Clinic, School of Medicine, University of Athens, Greece, the

study coordinator, reported that the study demonstrated that

moderate consumption of coffee by hypertensive elderly in-

dividuals can lead to improvements in aortic dispensability.

Aortic dispensability is a measure of the elasticity of arteries,

and low levels of dispensability have long been recognized

as an indicator of atherosclerosis and a reliable predictor of

future cardiovascular events. Aortic dispensability reflects ar-

terial aging. The study focused on a group of 235 (41% males)

hypertensive subjects and measured the impact of daily coffee

consumption using echocardiographic indices of aortic dis-

pensability, i.e. echocardiographic measurements of systolic

and diastolic diameters of the aortic root. The investigators

believe that the beneficial effects of drinkingGreek coffee is due

to the high concentrations of polyphenolic compounds found in

the traditional Greek coffee compared with the concentrations

of polyphenolic compounds in other coffees. Dr Chrysohoou

stated that the results showed that moderate coffee consump-

tion (between one and two cups of coffee daily) is associated

with higher values of aortic dispensability compared with other

hypertensive individuals drinking less quantities of coffee daily.

However, Dr Chrysohoou cautioned that increasing coffee con-

sumption to three to five cups daily would not lead to increased

benefit, since higher levels of caffeine lead to vasoconstriction,

which eliminates the beneficial effects of drinking coffee. The

question for the synthetic chemistry group in pharmaceutical

manufacturers is: could a synthesized derivative of the poly-

phenols inGreek coffee be the next cardiovascular wonder drug?

6. Statin Therapy and Cancer

In 1994, at the ESC annual meeting, the results of the

Scandinavian Simvastatin Survival Study (4S) were announced.

Professor Desmond Julian, now retired, former Professor of

Cardiology, University of Newcastle-upon-Tyne, UK, and

former Medical Director, British Heart Foundation and cur-

rently Editor-in-Chief and Chairman, InCirculation.net (www.

incirculation.net), has stated that the 4S trial totally changed

the treatment of hyperlipidaemia and made the general popu-

lation aware that high cholesterol was dangerous. Since then,

various studies have raised concerns that statins might cause

some types of cancer, particularly when blood cholesterol levels

were reduced to very low levels of cholesterol.

At this ESC annual meeting, Dr Jonathan Emberson, Senior

Statistician, Clinical Trial Service Unit and Epidemiological

Studies Unit, Oxford Cardiovascular Science, Oxford Univer-

sity, UK and holder of a fellowship from the British Heart

Foundation, Centre of Research Excellence, Oxford University,

UK, reported on the safety of statin therapy, a meta-analysis of

data on cancer from 170 000 participants in 26 randomized

trials. The Cholesterol Treatment Trialists’ (CTT) Collabora-

tion at the University of Oxford and the Clinical Trial Center at

theUniversity of Sydney,NSW,Australia, conducted themeta-

analysis. The analysis showed that cancer rates and deaths were

exactly the same in people taking statin therapy as those taking

a placebo. The investigators made the following three conclu-

sions: (i) there is no evidence that cancer risk is increased when

very low cholesterol levels are reached with high doses of

statins; (ii) there is no suggestion of an emergence of any hazard

with longer duration of treatment, at least within a period of

5 years; and (iii) because the trials analysed were, typically,

approximately 5-years duration, it is not possible to speculate

about the possible effects of longer term use. There is no evi-

dence that low cholesterol increases cancer risk at any site or in

any group of individuals. Furthermore, the results also showed

that there was no evidence that statins increase the risk of

cancer in the older patient, i.e. over 70 years old. The results of

this meta-analysis should reassure both the millions of people

worldwide who are taking statins and drug manufacturers that

there is no reason to suspect a causal link between statin ad-

ministration and cancer.

7. Ambulatory Measurement of Arrhythmia

and Atrial Fibrillation

Zenicor Medical Systems, Stockholm, Sweden (www.zeni

cor.se), has developed Zenicor-EKG, a wireless point-of-care

apparatus to accurately and remotely diagnose arrhythmia and

atrial fibrillation. The Zenicor-EKG system uses unique tech-

nology. The apparatus weighs approximately 150 grams with

the batteries, is small enough to fit into a pocket (145mm ·65mm · 25mm) and is European conformity (CE) marked. All

ages of patients, ranging from children to the elderly, can easily

use Zenicor-EKG. The patient puts both thumbs onto the small

apparatus and sends the results to the healthcare provider using

the built-in mobile phone.When a reading arrives in the Zenicor-

EKG system, the system will send an email to the healthcare

provider to notify him that his patient has sent a reading. The

healthcare provider can access the EKG data for his patient

from any computer with an internet connection. The patient

integrity is securedwithin the EKGdatabase.No installation or

specific software is required to use the Zenicor-EKG. The

healthcare provider can use the Zenicor-EKG device and the

European Society of Cardiology Congress 2010 297


EKG database in any country in Europe. The system has al-

ready been used successfully in several clinical trials in Sweden

as a tool for ambulatory measurement of arrhythmia and atrial

fibrillation.Normally, the patient uses the device for 2 to 4weeks,

registering their EKG twice a day and each time that symptoms

occur. The founders are in discussion with various pharma-

ceutical manufacturers, which plan to use the system to evaluate

the effectiveness of in-development medications or to re-evaluate

the effectiveness of marketed medications.

8. Evaluating Endothelial Function

Endothelial dysfunction is the earliest clinically detectable

stage of cardiovascular disease and predicts cardiovascular

outcomes more accurately than the Framingham risk score;

treatment of endothelial dysfunction modifies cardiovascular

outcome. The augmentation index is a measure of arterial

stiffness. ItamarMedical, Framingham,MA,USA (www.itamar-

medical.com) has developed Endo-PAT2000, which is a non-

invasive apparatus to evaluate endothelial function and measure

the augmentation index. Endo-PAT2000 is reliable, gives repro-

ducible results in 15 minutes, has been scientifically validated, is

user independent, is easy to use, can be used in a physician’s office

or in a hospital, it immediately and automatically analyses the

data and uses a control arm for systemic changes. Endo-PAT2000

has been approved by various regulators and is US FDA and

SHONIN (Japanese regulators) cleared, and has the CE mark.

Endo-PAT2000 has been used in more than 40 countries and has

also been used for research in approximately 15 pharmaceutical

clinical trials and ten population-based studies, including the

FraminghamHeart Study. An obvious advantage for the clinical

trial director is that Endo-PAT2000 gives reliable and repro-

ducible results that are not dependent on the particular clinical

trial centre.

9. Detection of Sleep Breathing Disorders

If left untreated, obstructive sleep apnoea can lead to hy-

pertension, cardiovascular disease, depression, motor vehicle

accidents and erectile dysfunction. Itamar Medical (Framing-

ham, MA, USA, [www.itamar-medical.com]) has developed

Watch-PAT, which is a validated non-invasive clinically proven

device for the accurate detection of sleep breathing disorders.

Watch-PAT is a portable device that is placed on the wrist, does

not require technical assistance for its use and can be used for

ambulatorymeasurement of sleep apnoea.Within a fewminutes

of receiving the data, theWatch-PAT system gives an automatic

analysis of respiratory disturbance index, apnoea hypopnoea

index, oxygen desaturation index, the various sleep stages (e.g.

REM sleep/non-REM sleep, wake/sleep, light sleep/deep sleep),heart rate, oxygen saturation, body position and snoring. The

system eliminates the need for subjective scoring of respiratory

events. Furthermore,Watch-PATgives information about sleep

comparable to the information obtained in a sleep laboratory in

a clinical setting. Many patients complain that they can not

sleep in a clinic. The clinical trial director, who must measure

sleep apnoea and sleep stages, could use theWatch-PAT system

to accurately, reliably, and rapidly (within 2minutes) obtain the

required data, eliminating the need to wait hours for the sleep

technologist in the clinic to analyse the data. Since the patient

can sleep in his/her own bed, Watch-Pat� yields data that ac-

curately evaluate the effect of a given medication on sleep and

sleep apnoea in the home setting.

10. Pharmacogenetic Analysis of Treatment

Benefit of ACE Inhibitors

For several years, pharmaceutical manufacturers have dis-

cussed the possibility of providing individualized therapy for a

patient that would optimize the therapy for that particular pa-

tient.Dr Jasper Brugts, Department ofCardiology, Thoraxcenter,

ErasmusMedicalCenter, Rotterdam, theNetherlands, presented

the poster ‘‘Genetic Determinants of Treatment Benefit of

Angiotensin Converting Enzyme (ACE)-Inhibitor Therapy in

Patients with Stable Coronary Artery Disease.’’[7] The advant-

ages of prescribing ACE inhibitors for stable coronary artery

disease may be increased by targeting the therapy to the pa-

tients most likely to benefit from ACE-inhibitor therapy. The

EUROPA (European Trial on Reduction of Cardiac Events with

Perindopril in Stable Coronary Artery Disease) trial enrolled

12 218 patients with stable coronary artery disease and com-

pared ACE-inhibitor therapy (perindopril) with placebo. With

4.2-years follow up, the ACE-inhibitor reduced cardiac death

and myocardial infarction by 20%. PERGENE (Perindopril

Genetic Association Study) is a sub-study of the EUROPA trial.

PERGENE is unique since it is the first large-scale pharmaco-

genetic analysis of treatment benefit of ACE inhibitors in a

randomized placebo-controlled trial in stable coronary artery

disease. PERGENE isolated and analysed DNA from 9454 sub-

jects in the EUROPA trial. Three single nucleotide polymorph-

isms (SNPs), located in the angiotension-II type I receptor genes

and bradykinin type I receptor genes were significantly associ-

ated with the treatment benefit of the ACE inhibitor perindo-

pril. A pharmacogenetic score, combining these three SNPs,

298 Kitler


demonstrated a stepwise reduction of risk in the placebo group

and a stepwise decrease in treatment benefit with an increasing

score. A pronounced treatment benefit was observed in a sub-

group of 73.5% of the patients, while no benefit was apparent in

the remaining 25.6%. Dr Brugts stated that if these finding are

confirmed in future clinical trials, these results may open the

road to individualize therapy by pharmacogenetic profiling. He

further stated that individualized therapy could revolutionize

ACE inhibitor therapy by prescribing ACE inhibitors only to

those patients most likely to benefit from the ACE inhibitor

therapy. Such individualized therapy would decrease the over-

all cost of ACE inhibitor therapy. Furthermore, if the develop-

ment of an ACE inhibitor was halted due to lack of efficacy in

the general population, it is possible that the use of pharmaco-

genetic profiling may reveal that the discarded ACE inhibitor

has outstanding beneficial effects in a particular population.

11. Public Health Burden of Atrial Fibrillation

Dr Christopher Wong, Cardiovascular Research Centre,

Royal Adelaide Hospital and the Discipline of Medicine, Uni-

versity of Adelaide, Adelaide, Australia, discussed the findings

of a study of nationwide trends for atrial fibrillation hospita-

lization in Australia (population 22 million) from 1993 to 2008.

Hospital admissions in Australia due to atrial fibrillation rose

by more than 200% over the 15-year period from 1993 to 2008.

Dr Wong emphasized that atrial fibrillation is the most common

sustained heart rhythm disorder in humans, affecting 15% of

people over the age of 80. If atrial fibrillation is not treated, the

atrial fibrillation can lead to strokes or death. More than one in

five strokes is due to atrial fibrillation and these findings impact on

the healthcare provider. The increase in the number of hospitali-

zations resulted in the number of days that atrial fibrillation

patients spent in the hospital increasing from 60000 days in 1993

to 150000 in 2008. This increase in the total number of days spent

in hospital happened in spite of the fact that the average number of

days each patient spent in hospital decreased from4.3 days in 1993

to 3.0 in 2008. Dr Wong concluded that the enormous public

health burden of atrial fibrillation on hospitals highlights the need

for better therapies and primary prevention strategies. To the

pharmaceutical manufacturers: are you listening?

12. Benefits of Exercise

Everyone knows that exercise is good for you. However,

many people do not exercise because they consider it boring and

others do not because they suffer from co-morbidities that do

not allow them to participate in high-intensity exercise. Pro-

fessor Heinz Drexel, Vorarlberg Institute for Vascular Investi-

gation and Treatment, Feldkirch and Department of Internal

Medicine, Academic Teaching Hospital, Feldkirch, Austria,

lives in a country where things are either up the hill or down the

hill. Professor Drexel conducted a study that enrolled 92

healthy sedentary individuals with an average age of 50 years

and who were moderately overweight. The study also had

25 control subjects with the same characteristics, who con-

tinued their normal lifestyle. The study subjects took a cable

car up the hill and then walked downhill, covering a height

distance of 600 metres in 45 minutes. The subjects walked

downhill three to five times each week for a period of 8 weeks.

The results showed that, in comparison to control subjects, the

subjects in the exercise programme statistically significantly

reduced the following study parameters: fasting glucose levels,

body mass index, C-reactive protein levels, triglyceride levels

and post-prandial leukocyte counts. The values were not

changed in the control subjects. This study showed that ec-

centric exercise, i.e. walking downhill, yields beneficial meta-

bolic and anti-inflammatory effects. Professor Drexel noted

that further studies to elucidate the intramuscular mechanisms

behind these effects may open up a new field of cardiometabolic

research, which will lead to breakthroughs in therapy from

innovative pharmaceutical manufacturers.

13. Targeting Childhood Obesity

Professor Yael Latzer, Associate Professor, Faculty of Social

Welfare and Health Studies, Haifa University and Director,

Eating Disorders Clinic, Psychiatric Division, Rambam Medi-

cal Center, Haifa, Israel, stated that parents are the key players

in the treatment of childhood obesity, which is an epidemic that

is rising in both industrialized and developing countries. In the

US, 10.4% of children aged 5–10 years and 15% of children aged

6–19 years are obese. In obese children seeking treatment, there

is evidence of increased levels of depression (48%), anxiety

(35%) and eating disorders (30%). Professor Latzer emphasized

that the need for efficient prevention and treatment is urgent.

Psychological problems of obese children are correlated with

parental psychiatric symptoms, parental eating and activity

behaviour and parental obesity rather than age, sex or body

mass index. Professor Latzer stated that the results in the

Eating Disorders Clinic in Haifa University showed that the

results of family intervention resulted in a significant im-

provement in blood pressure and serum cholesterol in the

children of the participants in the parent therapy groups. In the

heated discussion following the presentation, Professor Latzer

European Society of Cardiology Congress 2010 299


emphasized that targeting only parents and omitting the obese

child from the direct intervention, was associated with a greater

weight loss in the children. In the child-only group, children lost

8% of their weight but the children in the parent-only group

lost 15% of their weight. The results of the 7-year follow-up are

disappointing, since even in the superior intervention group,

most children remained substantially overweight. The conclu-

sion of the 7-year follow-up is that treatment still requires

improved interventions in terms of parent-only treatment.

Professor Latzer recommended that the intervention begin in

kindergarten. Thus, finding an efficient treatment is urgent.

The importance of collaborative multi-disciplinary involve-

ment among paediatricians, child and adolescent psychiatrists

and any other group involved in medicine and pharmaceuticals

is essential for primary prevention, evaluation, treatment and

relapse prevention.

Acknowledgements

DrKitler is a consultant atAssociates for Business andResearch, which

specializes in all issues relating to the pharmaceutical and biotechnology

industries and relating to public health.

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Correspondence: DrMary Ellen Kitler, Associates for Business and Research,

Rue A-Matringe 25, CH1180, Rolle, Switzerland.

300 Kitler
