The changing face of cardiovascular medicine: Insights from the European Society of Cardiology annual congress
Adya Misra, Senior Editor PLOS Medicine reports from the ESC annual congress in Paris
Every year approximately 30,000 researchers, medical doctors and policymakers come together to discuss the latest developments in Cardiovascular medicine. This year, I joined the European Society of Cardiology’s (ESC) annual congress in sunny Paris to learn how the field of cardiology is evolving within the rapidly changing landscape of medicine.
As I pored through the conference programme in the last few weeks, it became clear that another key topic stood out apart from interventional and preventative cardiology. The conference had a dedicated space to digital health this year, with talks on Artificial Intelligence, Machine learning, and wearable technologies. The use of telemedicine or digital health promises a revolution in healthcare utilisation and screening of high-risk undiagnosed individuals. It’s as easy as having an app on your smartphone that can measure your blood pressure or a wristwatch that can detect changes in your heartbeat and send alerts to you or your physician.
The Apple heart study was a frequent topic of conversation as it showed the feasibility of using the Apple Watch to detect atrial fibrillation in the general population. Out of 400,000 individuals, 0.5% were detected with atrial fibrillation, later confirmed by the physician during follow-up. On September 10th, Apple Inc launched three additional healthcare studies enabling sharing of healthcare data between individuals and researchers. Sounds exciting, but not everyone is thrilled at the prospect of sharing healthcare data widely.
The involvement of Amazon, Google, and Apple is raising red flags due to concerns surrounding privacy of healthcare data. There are also multiple concerns about losing patient-physician contact and that cardiologists will become obsolete. Professor Martin Cowie (Imperial College London) suggests it’s not all black and white and the role of the cardiologist is simply changing. Even the National Health Service (NHS) in the UK is encouraging citizens to try an app which can triage patients as an alternative to the NHS advice telephone line. Recent clinical trials have evaluated the benefit of remote monitoring patients with heart failure using wrist-based sensors. Professor Gerhard Hindricks (Leipzig University) told us that some studies reported a benefit to patients, in terms of a reduction in unscheduled physician visits and others showed no benefit or harm to the patients. Hindricks suggested this is due to a difference in processes and systems of data management, proposing centralised systems for multi-centre collaborations in remote monitoring trials.
Other big news included updates to the ESC guidelines this year, which saw a dramatic shift in certain areas of cardiovascular disease management. I heard Professor John McNeill (Monash University) about the use of aspirin as primary prevention of cardiovascular disease, highlighting three recently published trials that showed no evidence of benefit from aspirin. Three trials: ASPREE, ASCEND and ARRIVE showed no difference between aspirin and placebo groups with respect to cardiovascular outcomes. Unfortunately, the results show that aspirin confers a higher risk of severe bleeding a higher risk of net harm in elderly patients. McNeill told us this led to a change in the ESC guidelines that discourages the use of aspirin for primary prevention of cardiovascular disease. We also heard from Bryan Williams, who told us about the update in Hypertension guidelines this year. This year’s update suggests individualised blood pressure targets, rather than recommending a bog standard 140/85 mm Hg limit for everyone. Most importantly, the update this year includes patient tolerability as a factor to consider and provides a broader range of recommended targets for blood pressure.
Interventional cardiology stole the show at ESC as results from pharma-funded trials such as PARAGON-HF, THEMIS, ISAR-REACT 5, DAPA-HF and AFIRE created a lot of buzz in the press room. While all these trials report landmark, practice-changing findings, two trials stood out to me as the most interesting. The DAPA-HF trial reported that heart failure patients with preserved ejection fraction (HFpEF) who were given diabetes medication (sodium-glucose co-transporter-2 inhibitors) showed reduced worsening of heart failure and decreased risk of death. PARAGON-HF trial, on the other hand, aimed to understand whether a combination of drugs that works in heart failure patients with reduced ejection fraction (HFrEF) would also work for HFpEF patients. Interestingly, the reported results appear heterogeneous with benefits noted in women and in patients with a lower ejection fraction.
Preventative cardiology sessions were also popular at ESC, many with standing room only! The results of the PREDIMED trial from 2013 were presented on the first day, which hailed the Mediterranean diet as the saviour protecting us from obesity, diabetes and CVD. However, a recently published observational study in the BMJ suggests that vegetarians and fish eaters had lower rates of ischaemic heart disease, but vegetarians had higher rates of haemorrhagic stroke. Naveed Sattar (University of Glasgow) talked about the magical low-calorie diet and whether it works in patients with CVD. A randomised clinical trial published in 2018 showed that caloric restriction in diabetic patients to about 800cal/day using meal replacement lead to weight loss of up to 10kg over a year and remission to a non-diabetic state. While this clinical trial didn’t specifically look at CVD outcomes, the link between obesity and cardiovascular conditions remains strongly supported by more recently published observational studies and mendelian randomisation studies.
What’s the take-home message? Cardiovascular medicine is changing and adopting digital tools with open arms. There was a notable shift in cardiologists taking a more patient-centric approach. Everything at the conference from blood pressure targets to fitness tracker use was about patient tolerability and feasibility. This should hopefully help the patients who don’t benefit from treatment or often drop out of clinical trials because the targets are too unachievable.
Adya Misra, Ph.D. is a Senior Editor at PLOS Medicine, covering cardiovascular disease, obesity, diabetes and cancer. She has no competing interests to declare.
Photo credit: Adya Misra