European Society of Cardiology Congress (World Congress of Cardiology), August 31 –September 4, 2019 (Paris, France)
There were many outstanding developments presented at the 2019 ESC Congress. Here are the top 10 highlights of ESC Congress 2019.
General Cardiology
Ticagrelor in Patients with Stable Coronary Disease and Diabetes (THEMIS)1 was a highly anticipated study. This randomized, double-blind, placebo-controlled trial enrolled 19,220 patients in just over 2 years from 1315 enrolling sites across 42 countries. Diabetes patients with coronary artery disease and no prior myocardial infarction or stroke received ticagrelor or placebo, on top of aspirin. The primary efficacy endpoint was cardiovascular death, myocardial infarction, or stroke. Interestingly, at median follow-up of nearly 40 months, patients receiving ticagrelor had significantly lower rates of primary outcome. This was attributed to lower rates of myocardial infarction and ischemic stroke.
Interventional Cardiology
The COMPLETE2 trial included 4041 patients with ST-segment elevation myocardial infarction and multivessel disease treated with primary percutaneous coronary intervention (PCI). This randomized controlled trial (RCT) determined whether PCI of non-culprit lesions has additional clinical benefit. At median follow-up of 3 years, complete revascularization indeed reduced the rate of cardiovascular death or new myocardial infarction.
The SYNTAX Extended Survival (SYNTAXES) study3 provided 10-year follow-up data from the original trial. SYNTAX compared percutaneous coronary interventions (PCI) with coronary artery bypass grafting (CABG), using all-cause mortality as primary endpoint. While all-cause mortality did not differ between PCI and CABG in the overall cohort of 1800 patients, a survival benefit was seen for CABG in patients with three-vessel disease.
MITRA-FR4: The results after 24 months’ follow-up in 304 heart failure patients were no different from those presented last year. Percutaneous repair using the MitraClip gave no added benefit on top of optimal medical therapy for secondary mitral regurgitation. The risk of death or hospitalization for heart failure was similar in both groups.
ENTRUST-AF PCI5: This study assessed the safety of edoxaban in combination with P2Y12 inhibition in 1506 patients with atrial fibrillation undergoing PCI. The primary endpoint was a composite of incidence of major or clinically relevant non-major bleeding within 12 months. Compared with the control regimen (vitamin K antagonist, P2Y12 inhibition, aspirin), the edoxaban-based regimen was non-inferior in terms of bleeding.
Heart Failure
PARAGON-HF6 assessed the benefit of sacubitril/valsartan relative to valsartal alone in heart failure patients with preserved ejection fraction (LVEF ≥45%). The combination of sacubitril/valsartan did not reduce the rate of total hospitalizations for heart failure and death from cardiovascular causes.
DAPA HF7: When added to standard therapy, dapaglifozin reduced the risk of worsening heart failure and improved symptoms in heart failure patients with reduced ejection fraction. The risk reductions were substantial and consistent across subgroups, including patients without type 2 diabetes.
Acute Cardiac Care
The HISTORIC8 RCT included more than 30,000 consecutive patients with suspected acute coronary syndrome. A single cardiac troponin measurement safely and effectively ruled out myocardial infarction at presentation. The use of an optimized risk stratification threshold (<5 ng/L) reduced the length of stay. It also increased the proportion of patients discharged directly from the emergency department.
ISAR-REACT 59: Patients hospitalized for acute coronary syndrome who received an antiplatelet treatment strategy with prasugrel had better 1-year outcomes than patients who received ticagrelor. This result was the same for patients with and without ST-segment elevation.
New Lipid Guidelines
The ESC/EAS Task Force for the management of dyslipidemias has published new lipid guidelines10. One of the most striking recommendations is the lower target for LDL levels for most risk categories. The reasoning behind this is that risk reduction is directly proportional to the magnitude of LDL lowering. The guidelines now stipulate both a target LDL and at least a 50% reduction from baseline. Previous guidelines recommended just one of these two targets.
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Author: Sally Hill
References
3. Lancet 2019. DOI: 10.1016/S0140-6736(19)31997-X.
4. Eur J Heart Fail 2019. DOI: 10.1002/ejhf.1616.
5. Lancet 2019. DOI: 10.1016/S0140-6736(19)31872-0
6. NEJM 2019. DOI: 10.1056/NEJMoa1908655
7. Presented by J McMurray at ESC 2019. September 1, 2019. Paris, France.
8. Circulation 2019. DOI: 10.1161/CIRCULATIONAHA.119.042866Circulation.
