(Circulation. 2000;102:e9018.)
© 2000 American Heart Association, Inc.
Cardiovascular News |
Cardiovascular News
Fifty Years for the European Society of Cardiology
The European Society of Cardiology celebrated its 50th year in the city of Amsterdam, where a fleet of "tall ships" revived memories of the local past. At the same time, officials of the society at its 22nd Congress paid homage to the scientists and physicians who had gone before while heralding a future in which molecular biology and prevention will play a major role.
"This society began in 1950 with 14 national societies of
cardiology in the realization that without it, the
Americans would take over," said Lars Ryden, MD, outgoing society
president, in a tongue-in-cheek manner (Figure 1
).
Today, he said, the society represents at least 47 countries
with 26 working groups. The 2000 meeting attracted 23 000
participants.
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In his opening address, Dr Ryden called for cardiologists to collaborate with other specialists to improve the quality of care, particularly in settings that are not commonly frequented by specialists.
A museum at the 22nd Congress demonstrated the progress of heart care through the past 5 decades, starting with the debut of open heart surgery. However, the best is yet to come, said Udo Sechtem, MD, of the Abteilung fur Kardiologie, Robert Bosch Krankenhaus in Stuttgart, Germany, pointing to studies involving new methods of visualization, new molecules involved in diseases processes, and new understanding of inflammation and heart attack. Dr Sechtem headed the committee that set up the scientific portion of the program.
The Role of Heart Failure Clinics
Heart failure clinics could alleviate many of the problems associated with the diagnosis and treatment of that disorder, which is a growing problem in the industrialized world, said Tiny Jaarsma, MD, a consultant to the European Society of Cardiology’s cardiovascular nursing working group and a representative of the Netherlands Heart Foundation. However, she said, there is much disagreement about how such clinics should be structured. Should they be nurse-directed? Should they be primary care or cardiology clinics? Should they be outpatient or home care? "There is one issue that we all agree on," she said. "There is no debate that there is a need for extra care."
John Cleland, MD, of the Academic Cardiology Unit at Castle Hill Hospital, University of Hull, Kingston-upon-Hull in the United Kingdom, said recent studies demonstrate that cardiologists and primary care physicians in Europe accept many of the best treatments for heart failure, such as angiotensin-converting enzyme inhibitors. The use of ß-blockers is lower, but it is growing as the message gets to the general practitioner.
Dr Cleland agreed that there is a need for heart failure clinics, but he said it is mostly for the difficult-to-manage patients. "The pharmacological and nonpharmacological management of heart failure is becoming complex. Primary care physicians do need access to specialist resources and advice. Difficult patients with complex pharmacological regimes will need to be managed in a special clinic. You could have a combination of 7 to 8 medications with patients who also need cardiac resynchronization and revascularization."
However, Dr Cleland said, there is no way that specialized heart failure clinics can keep up with the volume of patients who have the disorder. Dr Jaarsma said that in the industrialized nations, 2% of those between the ages 55 and 65 have heart failure, and 10% of people aged 80 or more have the disease.
Ferenc Follath, MD, of the University Hospital in Zurich, said that in considering such clinics, one must remember that the typical patient with heart failure is over the age of 70 and more likely to be female than male. At least two-thirds of such patients suffer from other diseases, such as diabetes or lung problems. Those factors must be taken into account when drug regimens are prescribed.
Most of such patients, said Dr Follath, are treated by primary care practitioners. Surveys show that such doctors provide very good care. Dr Follath noted his experience has been that the nurses who follow-up with the patients are important to long-term care and social support. A nurse might discover that patients are forgetting to take their medicines, have not received calls from hospitals, and are not seeing their primary care physicians. "These are very simple things that will be very helpful to prevent deterioration."
Dr Cleland pointed out that in some university hospitals, the heart failure clinics are run basically for patients who will someday qualify for heart transplants. "This is a small number of people, and there are lots of people with heart failure who would not receive care there."
Hugo Madeira, MD, a professor at the Faculdade de Medicina de Lisboa in Lisbon, said, "The key word is close monitoring, whether the patient comes to the heart failure clinic or whether the clinic goes to the patient’s home."
Gene Manipulation in Heart Failure
Although promising in vitro and animal work indicates that the manipulation of the genes involved in the production of cytokines, their receptors, and various other proteins in cells could play a role in the treatment of heart failure, the work is not yet ready for clinical practice, said Ketty Schwartz, MD, a professor at the Institute of Myologie, INSERM, Paris, in summing up a session on gene manipulation.
Although some of the studies described at the Amsterdam meeting could be considered preclinical, she said there is much to be accomplished before the work is translated to the bedside. However, despite current pessimism about the field of gene therapy, Dr Schwartz is confident that such treatments will become important in the treatment of all heart disease.
Recent success in the treatment of children with X-linked severe combined immune deficiency (Science. 2000;288;669–672) may have been overshadowed by safety concerns raised in the United States. However, Dr Schwartz noted that "this gloomy picture is not true and important success has been achieved." Most gene therapy trials currently underway deal with cancer patients. Patients with stage IV heart failure are very similar to heart failure patients, and it may one day be possible to try gene therapy in this disorder as well, starting with patients who are the sickest.
Oral Glycoprotein IIb/IIIa Inhibitors: What Went Wrong?
The fact that previous studies of the current generation of oral glycoprotein IIb/IIIa inhibitors have been disappointing is a tragedy in 2 senses, said John F. Martin, MD, a professor in the Department of Medicine and the Centre of Vascular Biology and Medicine at University College of London. "Patients died, but the story is economically tragic as well. The development of drugs is expensive and (by comparison) science is cheap. It would have been better to invest in good basic science before going into these clinical trials."
Maarten L. Simoons, MD, incoming European Society of
Cardiology president and a professor at the University
Hospital in Rotterdam, The Netherlands (Figure 2), held out hope that
further generations of oral glycoprotein IIb/IIIa
inhibitors would be more valuable. He noted that "These
drugs do work intravenously. Patients who receive these
drugs do have a reduction in procedure-associated events."
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"What went wrong? We didn’t know enough about platelet receptors. We should do more basic science there. Many of us in industry and in universities were too hasty to do large trials," said Dr Simoons. He said new agents in this class should have a longer half-life with a high bioavailability. Individualized dose titration must be considered, and such drugs may be reserved for patients in the populations at higher risk for adverse events without treatment.
Stratifying patient groups to determine who benefited from the treatment might be important in determining who should and should not undergo these kinds of treatments, said Dr Simoons. He said he does not know if the difference in effect between the oral and intravenous forms of the drugs is due to pharmacology or a if it is a "matter of the condition of the patient and the dose-level you can achieve."
Public Access Defibrillation Comes to Europe
When Rudolph W. Koster, MD, pulled out a small, notebook-sized
yellow electronic instrument in a press conference at the 22nd Congress
of the European Society of Cardiology at a press
conference, the media were all eyes and ears (Figure 3). He was
explaining recently published international resuscitation guidelines
that call for worldwide public access defibrillation. For many medical
journalists at the meeting, it was their first contact with an
automatic external defibrillator (AED).
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Dr Koster, an Amsterdam cardiologist, said, "If someone collapses outside the hospital, it is almost always caused by ventricular fibrillation and coronary artery disease. You have to act rapidly because you have to defibrillate the patient within (at best) 1 to 2 minutes and, at the most, 5 to 6 minutes. The chance of survival is small without that."
However, early defibrillation is unlikely to occur as long as patients must wait many minutes for an ambulance to arrive. Although cardiopulmonary resuscitation with chest compression and mouth-to-mouth breathing is important, waiting 10 minutes for defibrillation can decrease survival to one-fourth what it would have been if the procedure had occurred within 1 to 2 minutes.
More than half of ambulances arrive within 10 minutes, and the rest arrive later, said Dr Koster. It is virtually impossible for most ambulances to cut that time significantly.
In a statement issued by the American Heart Association, the European Resuscitation Council, the European Society of Cardiology, and others, the societies pushed for more widespread use of the AEDs in an effort to cut deaths from people whose hearts stop on the streets, in public arenas, and other out-of-hospital locations.
One issue that must be resolved is the legal implications of using such a machine, said Dr Koster. AEDs are already deployed throughout the United States, and specific state laws protect individuals who use the machines in an emergency. Similar legislation may be needed in European countries. Current recommendations would put the machines in the hands of police and firefighters, who are often the first responders to a call for help. However, Dr Koster anticipates that use by the general public will receive a recommendation as well.
A US study to test the effects of public access defibrillation will determine how widely spread such units will become. The study, which was funded by the National Heart, Lung and Blood Institute in collaboration with the American Heart Association, was launched in August. The multicenter trial will test the life-saving potential and cost-effectiveness of public access defibrillation.
"We want to know if placing these devices in the community where trained volunteers could access them will prevent additional deaths and whether such a program is feasible," said Claude Lenfant, MD, director of the Institute.
"The American Heart Association recognizes that the early use of defibrillators provides the most effective treatment for the majority of sudden cardiac arrest victims," said American Heart Association President-elect Rose Marie Robertson, MD. "This study will measure the effectiveness of the trained lay responders who treat sudden cardiac arrest using AEDs, and the results will help communities across the country to design the best public access defibrillation programs possible."
The study will last 2.5 years and be performed in 24 centers in the United States and Canada. Volunteers will be trained to recognize cardiac arrest, to access the 911 system, and to perform cardiopulmonary resuscitation. Half of the communities will have AEDs placed in conspicuous locations. Volunteers will be trained in their use as well. The other communities will provide usual emergency care without AEDs.
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