Top 10 highlights of ESC Congress 2020

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This year’s European Society of Cardiology (ESC) congress was the first ever to be held entirely digitally, due to the COVID-19 pandemic. Approximately 116,000 healthcare providers from 211 countries participated, and there were many illuminating presentations shared to help guide the management of cardiovascular disease. Here are our top 10 highlights listed by topic.

General Cardiology

EXPLORER-HCM trial¹: New drug option for obstructive hypertrophic cardiomyopathy. This Phase III study administered mavacamten, a cardiac myosin inhibitor, or a placebo, to 251 patients with symptomatic obstructive hypertrophic cardiomyopathy for 30 weeks. Patients on mavacamten had greater reductions than those on placebo in post-exercise LVOT gradient, greater increase in pVO₂, and improved symptom scores. More patients in the mavacamten group improved by at least one New York Heart Association symptom class.

BPLTTC: Antihypertensive drugs lower CV events across BP levels, irrespective of prior CVD. The Blood Pressure Lowering Treatment Trialists Collaboration (BPLTTC)², a meta-analysis of 48 randomized clinical trials, found a reduced risk of cardiovascular events with antihypertensive therapy, even in people with no prior heart disease and in people with normal blood pressure. Researcher Kazem Rahimi, MD, DM (University of Oxford, England) speculates that these results may challenge current treatment protocols, which are dictated by prior disease and blood pressure. However, Hans Reitsma, MD, PhD (University Medical Center, Utrecht, the Netherlands), cautions that further analyses are needed, especially on side effects. Reitsma insists decisions must be made shared between clinicians and patients, because benefits of taking the antihypertensives must be balanced with the associated side effects.

LoDoCo2 trial: Colchicine protective in chronic coronary disease. In the placebo-controlled randomized LoDoCo2 trial³ (n = 5522), the patients with chronic coronary disease who were given colchicine experienced a lower risk of cardiovascular events than those who were given a placebo. While these findings support the growing body of evidence of the role of inflammation in cardiovascular disease, the study failed to monitor levels of inflammatory markers. Only 15% of the participants were women, a shortcoming that needs to be addressed in future trials. There is some concern regarding GI intolerance of colchicine, and drug interactions need to be carefully explored.

Heart Failure

EMPEROR REDUCED trial: Empagliflozin reduced CV death and hospitalization from heart failure. The EMPEROR-Reduced trial⁴ randomly assigned 3730 patients to receive empagliflozin (an oral sodium-glucose co-transporter 2 inhibitor) or placebo over a median of 16 months. Patients had class II, III, or IV heart failure and an ejection fraction of 40% or less. Patients also participated in recommended therapy. Patients in the empagliflozin group had a lower risk of cardiovascular death or hospitalization for heart failure than those in the placebo group, regardless of the presence or absence of diabetes.

Cardiac Surgery

POPular CABG trial:  Ticagrelor did not reduce SV graft occlusion after CABG. The POPular CABG trial⁵ investigated the effect using ticagrelor plus aspirin versus aspirin alone on saphenous vein graft (SVG) patency. 499 patients were followed for one year following coronary artery bypass graft surgery (CABG). The randomized, placebo-controlled trial showed that adding ticagrelor to standard aspirin did not reduce SVG occlusion one year after CABG.

Interventional Cardiology

POPular TAVI trial: Aspirin alone after TAVI in antithrombotic treatment The POPular TAVI trial⁶ compared single and dual antiplatelet treatment on bleeding and thromboembolic events after transcatheter aortic-valve implantation (TAVI). 331 patients undergoing TAVI, without indication for anticoagulation, were assigned to receive aspirin or aspirin plus clopidogrel for 3 months. After one year, bleeding and thromboembolic events were significantly less frequent in patients receiving aspirin only.

ATPCI trial: Long term trimetazidine safe but not preventative of angina or adverse outcome after PCI. The ATPCI trial⁷ followed 6007 patients receiving either trimetazidine or a placebo, following successful percutaneous coronary intervention (PCI). After a median follow-up of 47.5 months, trimetazidine did not improve either the outcome or the occurrence of angina.

Atrial Fibrillation

EAST-AFNET 4 trial: Early rhythm control in AF patients. The EAST-AFNET 4 trial⁸ found that early rhythm-control therapy was associated with a lower risk of cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions. Early rhythm control included treatment with anti-arrhythmic drugs or atrial fibrillation ablation after randomization.

ELDERCARE-AF: Low dose Edoxaban protective in frail elderly AF patients. This Phase 3 multicenter, randomized, double-blind, placebo controlled trial⁹ examined a once daily 15 mg dose of edoxaban vs placebo in elderly Japenese patients (≥80 years) with nonvalvular atrial fibrillation. Qualifying patients were deemed not suitable candidates for dosages approved for stroke prevention. 984 patients were randomly assigned in a 1:1 ratio and revealed that a once-daily 15 mg dose of edoxaban was superior to placebo in preventing stroke or systemic embolism. In addition, the low dose anticoagulant did not result in significantly increased incidence of major bleeding events.  

New guidelines

The European Society of Cardiology (ESC), in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) has published new atrial fibrillation management guidelines¹⁰. One of the most notable changes is the proposal of the “4S-AF” scheme to characterize atrial fibrillation. The ‘S’ components are: Stroke risk, severity of Symptoms, Severity of atrial fibrillation burden, and Substrate severity. This shift from a single-domain conventional classification of AF is felt to yield a more precise assessment of AF because it has the capacity to incorporate whatever new information may become available across these four domains. Throughout the new guidelines, there is an emphasis on streamlining integrated care with the Atrial fibrillation Better Care (ABC) pathway. The ABC pathway is comprised of ‘A’ for Anticoagulation/Avoid stroke, ‘B’ for Better symptom Control, and ‘C’ for Comorbidity/Cardiovascular risk factor optimization.

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Author: Kelly Schoonderwoerd

References

1. Olivotto I, et al. Lancet. 2020.
2. Rahimi K. Pharmacological blood pressure-lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure. Presented at: ESC 2020. August 31, 2020.
3. Nidorf SM, et al. N Engl J Med. 2020.
4. Packer M, et al. N Engl J Med. 2020.
5. Willemsen et al. Circulation. 2020 Aug 31.
6. Brouwer J, et al. N Engl J Med. 2020.
7. Ferrari R, et al. Lancet. 2020.
8. Kirchhof P, et al. N Engl J Med. 2020.
9. Okumura K, et al. N Engl J Med 2020.
10. Hindricks G, et al. Eur Heart J. 2020. 00: 1-125.