Editor: Jiamo Ren
Recently, ESC 2022 has been successfully concluded. The conference brought a unique academic feast to cardiovascular experts and scholars around the world, covering the latest guidelines, latest research and hotline conferences. The journal specially invites experts from the University of Barcelona, Spain, Professor Elena Arbelo from the Cardiovascular Research Institute to take you to experience the highlights of the event!
International Circulation: Several new guidelines and studies were presented at this year's conference,which research are you most interested in?
Professor Elena Arbelo: The ESC Congress is an amazing opportunity to highlight and learn about the new recommendations that have been published this year. We have had four new Guidelines. One is the ventricular arrhythmia guideline and the prevention of sudden cardiac death. I am particularly fond of this Guideline as it is my field of expertise - the arrhythmias, including atrial fibrillation and sudden cardiac death. The nice thing about this Guideline is that it incorporates a lot of new evidence. It highlights the importance of properly evaluating patients for sudden cardiac death, which is one of the leading causes of death worldwide. There is a very specific evaluation pathway, including new technologies, like genetic testing. It is very important to evaluate in survivors of cardiac death and in cases of death, the autopsy results, with specialized pathologists, the different possibilities and underlying pathologies to prevent sudden cardiac death, both in surviving patients and family relatives. So the Guidelines give a lot of guidance in general, and also guidance in the specific entities, including ischemic heart disease, cardiomyopathies, primary arrhythmias of the heart, and other contexts where individuals have a high risk of ventricular arrhythmias and sudden death.
There are another three Guidelines. One is the the Cardio-Oncology Guideline. This is the first edition of this Guideline, because there is growing evidence that there is a big relationship between cardiology and oncology, and in particular, patients with cancer who may have pre-existing heart disease that may nullify the treatment and prognosis of a concurrent cancer. And on the other hand, cancer therapies may be associated with increased risk of developing left ventricular dysfunction or heart problems. Therefore, these Guidelines are very useful, as they explain how patients need to be evaluated. Firstly at baseline, usually just an ECG, and from there, depending on the findings, you may need to do some extra tests. And then, which medications may affect the heart, how often you should follow these patients up, and what should management be after the cancer has been treated, depending on whether the patient had or didn’t have concomitant heart disease.
The third Guideline was for pulmonary hypertension. Pulmonary hypertension is a rare consideration - not many cardiologists are comfortable with or know about this, so it is going to be helpful for the implementation of evidence-based recommendations. There have been new therapies in the last few years that have come up for these individuals, and that is why this guideline is so useful. Finally, there is the non-cardiac surgery Guideline, which is also a very relevant topic. There are so many patients undergoing any type of surgery worldwide, some of them are low-risk, and some of them are high-risk, and they may have underlying heart disease. In order to prevent cardiovascular complications of these surgeries, this Guideline is very important.
There are two patient Guidelines, and these Patient Guidelines are particularly interesting because they have been designed in collaboration with the ESC Patient Forum and patient experts. In the field of preventative cardiology, this will promote and facilitate the implementation of the Guidelines so patients can understand the evidence-based recommendations so they can be implemented easily, because these guidelines are written for the general population to understand. In terms of research, there have been so many fascinating randomized clinical trials and other types of trials. The Hot Line Sessions have shown many different aspects. Several of them, at least in conversations with my colleagues and on social media, will have a major impact. For instance, we have the PERSPECTIVE trial that evaluates sacubitril/valsartan compared to valsartan only in cognitive function in patients with heart failure and preserved left ventricular ejection fraction. This was randomized. There was some concern that this drug increased the deposition of beta-amyloid and decreased cognitive function, but this shows that it is safe to use it, because there is no evidence that adding sacubitril to valsartan increases this risk or decreases cognitive function. The SECURE trial concerns secondary prevention of cardiovascular disease in the elderly. It revolves around the concept of the polypill that contains aspirin, atorvastatin, and ramipril, which results in a significant reduction of cardiovascular events compared to usual care. That is very interesting. Another study compared the timing of blood pressure reducing drugs, and whether it is better to give them at night or in the morning. They saw no differences, and that allows us as professionals to choose the better option for our patients without concerns.
Then we have other studies in acute heart failure, like the ADVOR study, which compared the addition of acetazolamide to conventional diuretics in acute heart failure to improve outcomes. It appears to be favorable. The BOX trial evaluated high intensity oxygenation compared to reduced, and found no differences in the context of cardiac arrest survivors. The DANCAVAS study evaluated the outcomes of screening for cardiovascular disease based on cardiac CT and root CT to rule out vascular disease and coronary disease. The comparison of brachial and ankle blood pressure to rule out peripheral vascular disease with blood tests was able to identify, mainly in a certain group of patients between 65 and 70 years of age, improvements in outcomes. In the overall population (65-74 year old men), it did not show an overall benefit, so any benefit is only seen in the younger age groups.
Also we have the DANFLU-1 study comparing high-dose influenza vaccination to the regular standard dose, and apparently the high dose reduced cardiovascular morbidity and mortality. I can continue, as there are many more. We have the ALL-HEART study evaluating the addition of allopurinol to prevent adverse cardiovascular outcomes in ischemic heart disease, but this did not show any benefit. Artificial intelligence. We have several studies that were presented regarding artificial intelligence. One of them was the EchoNet-RCT where they evaluated the accuracy of left ventricular ejection fraction calculation standard-of-care (which is done by sonographers) versus an artificial intelligence-derived algorithm and assessed blindly by a cardiologist, and the AI algorithm performed much better than the sonographer-guided classification of left ventricular ejection fraction. We have the eBRAVE-AF trial, which is a smart phone-based screening using AI for atrial fibrillation. It shows that in more than 65000 individuals with recorders that were using artificial intelligence, AI improved the accuracy of screening for atrial fibrillation, and subsequently increases the anti-coagulation management. AI has also been shown to be better at classifying and evaluating the severity of aortic stenosis, and with this AI-based classification, can predict prognosis. Also, AI has been used to estimate overall cardiovascular risk by introducing the concept of causal modification. When you have modifiable risk factors instead of introducing them as a static concept, when using AI you may modify the effect of treating these modifiable causes and this better predicts the overall cardiovascular risk in a population. Other major studies in the field have been in atrial fibrillation.
INVICTUS evaluated rivaroxaban in rheumatic heart disease, mainly in patients from Asia, Africa and Latin America with rheumatic heart disease and mitral stenosis. Basically, they found that the vitamin K antagonists are better and have a better profile in preventing mortality and ischemic stroke compared to rivaroxaban. They didn’t increase the risk of bleeding, so vitamin K antagonists are still the treatment of choice in rheumatic heart disease. Also related to anticoagulation, we have the Factor XI inhibitors. They have been studied in AXIOMATIC with milvexian evaluating secondary stroke prevention. It is a phase III trial, and shows promise in terms of preventing stroke. Basically, what was found was that there was not a dose response, but around a 30% relative risk reduction in stroke, without any fatal bleeding or intracranial hemorrhage. That is very promising.
Also, in the same field of Factor XI inhibitors, we have asundexian from different arms of the PACIFIC study. The acute myocardial infarction arm was presented, and so was the stroke arm. They showed promising results in terms of being able to be administered in association with antiplatelet therapy. This, of course, needs to be validated in phase III trials. In the field of heart failure, we have heard about dapagliflozin in patients with mildly reduced or preserved ejection fraction. It showed a risk reduction in patients with reduced ejection fraction, making it a new tool in this pool of patients for whom we hardly have any medications to treat them with. Then we have the REVIVED-BCIS2 study, where they evaluated patients with severe LV dysfunction and extensive coronary artery disease that could be revascularized with evidence of ischemia with PCI. Unfortunately this study, surprisingly showed no additional benefit in those patients undergoing revascularization in terms of all-cause mortality or hospitalization for heart failure. There are plenty of other studies, but I think I have highlighted some of the ones I would consider to be good.
International Circulation: What is the application status and progress of AI technology in atrial fibrillation management?
Professor Elena Arbelo: Artificial intelligence in atrial fibrillation has several possible applications. During this Congress, multiple studies have been presented. I guess I would highlight one of those that I mentioned, the eBRAVE-AF study, for screening. Here, I feel artificial intelligence is going to be key. We now have lots of in-house smart devices (watches, wristbands, monitors) that are able to detect and identify atrial fibrillation. Based on the Guidelines, AF needs to be confirmed by a 12-lead ECG or a 30-second recording evaluated by a healthcare professional. If artificial intelligence proves to be reliable, it is going to significantly improve the reach that we have through the smart devices that so many people have access to. The other area where artificial intelligence is very promising is personalizing the management of patients. There have been several presentations. One I would like to highlight is the one for tailoring the ablation therapy to the actual substrate of patients. In theory (and of course this is still in development), if you have a model of the patient’s heart and if you identify appropriately the distribution of the scar together with other characteristics of the patient introduced in to the AI model, you can simulate what happens by ablating different areas of the heart and how you can modify the substrate. The aim of this is to guide or tailor the ablation therapy to the specific individual with specific anatomic and electrophysiological characteristics. A randomized clinical trial is going to be started in the US, and we will see whether these results are applicable to everyday clinical practice or not.
Not related to artificial intelligence, but in the field of ablation, I would highlight there was also a presentation on pulsed field ablation, and that is also a very promising technology with a whole new concept. It simplifies the procedure, using safer energy levels with higher success rates with a standardized procedure. So pulmonary vein isolation and achieving a complete and durable block safely is a very promising area in atrial fibrillation ablation.
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