22nd Congress of the European Society of Cardiology, Amsterdam

This year's lay media story at last month's annual ESC meeting appears to have been the news from the Global Registry of Acute Coronary Events (GRACE) that there is a need for better treatment practices in the UK's management of acute coronary syndromes. According to data presented by Keith Fox (Edinburgh, UK) unfractionated heparin is still more widely used than low-molecular-weight heparin in the treatment of non-Q-wave myocardial infarction (MI) and unstable angina. Furthermore, over 30% of patients with acute MIs who would qualify for urgent clotbusting drugs and/or angioplasty do not receive these potentially life-saving treatments. Among the facts revealed in GRACE was that GPIIb/IIIa inhibitors are used in only 19% of MI cases and 6% of unstable angina patients. When these treatments are used, however, the ideal choice appears to be far from clear. Results of a meta-analysis comparing abciximab, tirofiban and eptifibatide in patients undergoing PTCA — based on 12 previously published studies on approximately 18,000 patients — were reported by Philip R Reid (Indianapolis, USA). The efficacy endpoint was a combination of death or non-fatal MI, and safety endpoints included bleeding and thrombocytopenia. Abciximab-treated patients had the greatest reduction in the combined endpoint at 30 days compared with placebo, and the analysis estimated that abciximab could prevent one death or non-fatal heart attack at 30 days for every 25 patients treated. In comparison, 55 patients would need to be treated with tirofiban and 66 with eptifibatide to achieve similar results. A double-blind randomised pharmaco-economic study in Springfield, USA suggested that high-dose eptifibatide provided in-hospital cost savings and appeared to be as safe and effective as abciximab in 320 non-high-risk patients undergoing elective PTCA. Frank V Aguirre reported there was a significant (p=0.009) in-hospital total cost difference between the patient groups of $704. The cost savings was largely attributable to a reduction in pharmacy costs between eplifibatide-treated ($505) and abciximab-treated ($1602) patients (p=0.001). The composite efficacy endpoint (death, non-fatal MI and need for urgent repeat revascularisation) was similar in both treatment arms. The findings from the GUSTO IV-ACS trial, which evaluated the safety and efficacy of abciximab in patients with acute coronary syndrome when a coronary intervention was not planned, found that the treatment arm did not show a statistically significant benefit over the placebo group. The combined endpoint of death or Ml at 30 days was 8% in the placebo group, 8.2% in abciximab patients receiving treatment for 24 hours and 9.1% in abciximab patients receiving treatment for 48 hours. Maarten Simoons (Rotterdam, Netherlands) said the most appropriate use of abciximab was in patients undergoing angioplasty or stenting, since its value had been shown in nine previous trials in over 9000 patients. The Lipid Assessment Trial Italian Network (LATIN) study in over 1200 patients with MI or unstable angina was conducted to determine the variation of lipids levels throughout the course of acute MI and unstable angina, so as to assess the best moment to measure the true cholesterol level. A DiCiara (Udine, Italy) reported that cholesterol levels drop shortly after the onset of an acute MI, which can lead to substantial undertreatment of the patient. It was recommended that to treat all dyslipidaemic patients, cholesterol determination should be done at hospital admission. Recent clinical trials have consistently shown that statins can prevent complications and deaths from cardiovascular disease in adults with hypercholesterolaemia and it is now being debated whether their observed benefits are due primarily to changes in blood cholesterol levels or other drug effects. Steven A Grover et al (Montreal, Canada) analysed the results of 15 published clinical trials and concluded that the reduction in coronary events was associated with reduced LDL-C levels. Earlier studies, however, had demonstrated that the ratio of LDL-C to HDL-C was a much stronger predictor of coronary risk than LDL-C alone. When the change in HDL-C was included in the analyses of treatment, the changes in blood lipid levels better explained the reduction in coronary events observed across studies. For example, those studies with the smallest changes in the LDL/HDL ratio were associated with only a 23% reduction in coronary death, while in studies with the largest change in ratio, there was a 39% reduction in coronary death. Using hierarchical meta-analyses, they found the likelihood that a positive relationship exists between changes in blood cholesterol levels and a reduction in coronary events, ranged from 76% to 86%. If only the five major landmark studies were analysed, the likelihood that changes in cholesterol levels are associated with a reduction in coronary deaths rose to 96%. Findings from the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey revealed that although most physicians state they use guidelines on the prevention and management of CHD, those for cholesterol are not being properly implemented. These data are consistent with those from earlier studies showing that undertreatment of high cholesterol in CHD patients is widespread. While 90% of REACT physicians agreed with the content of high cholesterol management guidelines, almost half acknowledged that high cholesterol was generally not treated sufficiently aggressively. A study presented by Andrew Neil (Oxford, UK) showed cholesterol benefits from a plant sterol-enriched spread. Sixty-two people with hypercholesterolaemia (of whom 30 were also taking statins) took 25g of the spread daily. The results showed a 10–15% reduction in LDL-C cholesterol over the full eight-week study period, while HDL-C remained unchanged. The results showed similar cholesterol reductions, whether the spread was used in addition to statins or not. Dr Neil observed that the significant reduction in LDL-C could reduce the risk of coronary heart disease by up to 20%. Johannes Schaar and colleagues from Essen, Germany have developed a teaching programme for patients with known coronary artery disease designed to encourage self-management of risk factors. To test the effect of cholesterol self-measurement, 135 patients with coronary artery disease and hyperlipidaemia were divided into two groups: a teaching-only group and a teaching plus self-measurement group. All patients received a statin in a standard dose. At six months, cholesterol and LDL-levels were significant lowered in the self-assessment group compared with the leaching group (p<0.005 and p<0.01 respectively). Atrial fibrillation is the commonest arrhythmia in the western world with 2–4% of people over 60 years suffering from it (which can increase to 40% of patients with concomitant cardiac disease, such as overt congestive heart failure), according to Robert G Tieleman (Groningen, Netherlands). Dr Tieleman presented results of a study demonstrating that, in patients with atrial fibrillation, there is clinical evidence for recovery from atrial electrical remodelling, and that such patients could benefit from an aggressive and rapid treatment of a recurrence of the condition after a previous cardioversion. Before inclusion, patients with an episode of chronic atrial fibrillation ranging from one month to one year underwent an infusion with a weight-adjusted dose of i.v. flecainide. As expected, because of the long arrhythmia duration, none of the patients converted to sinus rhythm. Subsequently, 181 patients were treated with an electrical cardioversion. When normal sinus rhythm was restored, the patients' heart rhythms were checked three times a day for one month. In case of a relapse, a second infusion with flecainide was administered. During follow-up, 123 patients (68%) experienced a recurrence of atrial fibrillation. In seven patients the second flecainide infusion was successful in restoring sinus rhythm, despite the proven ineffectiveness at study entry. The results of this study demonstrated that recovery from atrial electrical remodelling can be of clinical use. More bad news for smokers. Reminding us that active cigarette smoking is associated with a 20% increase in cardiac mortality and doubles the risk for coronary artery disease, Makris Stavroulakis (Athens, Greece) pointed out that passive smoking, although associated with a smaller risk, leads to a substantial number of events, given the high prevalence of exposure. Meanwhile, Ron van Domburg (Rotterdam, Netherlands) reported that patients who successfully quit smoking after bypass surgery had a significant 44% lower risk of death than those who continued to smoke after surgery. Other data from the long-term follow-up of over 1000 patients who had CABG in the 1970s found that of the 53% who were original smokers 43% had successfully given up the habit. But do patients always tell the truth about their smoking habits? Not necessarily, said Mona Attebring (Goteborg, Sweden). An outpatient clinic questionnaire of 554 patients who had been hospitalised with various acute myocardial conditions revealed that 18% smoked at the time of their visit, 27% had never smoked and 56% said they had quit. However, lab tests showed that 6.5% of those who claimed to have stopped had values of chemical markers that contradicted their claims. But the news is better for (moderate) drinkers who do not smoke. A French study asked why alcohol appeared to increase the levels of intercellular adhesion molecule (ICAM) implicated in atherogenesis. Further analysis showed that the levels of ICAM were elevated in those drinkers who also smoked, while they did not differ between drinkers and non-drinkers. As drinkers were more often smokers than non-drinkers, the investigators, from Toulouse, concluded the high levels of ICAM found in drinkers could be accounted for by the higher tobacco consumption in this group. A study from Ulm, Germany reported by W Koenig and colleagues suggests moderate alcohol intake may lower C-reactive protein (CRP) levels. The mechanisms are not yet understood, but non-drinkers and heavy drinkers had elevated levels of CRP. While the authors do not recommend alcohol consumption in previous non-smokers, they do suggest their data indicate beneficial effects of moderate drinking. A symposium organised by the manufacturer of a popular confectionary presented research suggesting chocolate may help to maintain heart health. Apparently cocoa polyphenols (present in the cocoa in chocolate) help to relax blood vessels, act like antioxidants and may be antithrombogenic. In addition, the main fat in chocolate, stearic acid, exerts a neutral effect on cholesterol. Another study suggested that caffeine activates sympathetic nerve activity and increases systolic and diastolic blood pressure; thus coffee drinking causes an increase in sympathetic nerve activity, associated with an increase in blood pressure in non-habitual coffee drinkers. One solution is to drink cappuccino, where the hypertensive effects of a nice strong cup of coffee are attenuated by a decent sprinkling of vasodilating powdered chocolate on top.

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