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ESC 2011

ESC 2011. Nick Collins September 2011. What’s Hot… Lining up Enormous > 30, 000 delegates Guidelines ESC TAVI Refreshing Oral anticoagulation Focus Chocolate Crepes. What’s Not…. Foie Gras Too rich Almangac Too much burning of oral mucosa Prasugrel Ticagrelor Clopidogrel

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ESC 2011

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  1. ESC 2011 Nick Collins September 2011

  2. What’s Hot… • Lining up • Enormous • > 30, 000 delegates • Guidelines • ESC • TAVI • Refreshing • Oral anticoagulation • Focus • Chocolate Crepes • What’s Not…. • Foie Gras • Too rich • Almangac • Too much burning of oral mucosa • Prasugrel • Ticagrelor • Clopidogrel • Warfarin

  3. Outline • Overview • Not reviewed paper • Simultaneously published • Summary • Pique interest • Details lacking • Jonathan…..

  4. ARISTOTLE • Seminal paper • Most interest • Apixiban • Factor Xa inhibitor • Differs to dabigatran • ROCKET AF • Rivaroxaban • Potency • Reflection dose • Dosing wars • Double blind • Non inferior compared to warfarin

  5. ARISTOTLE • NEJM • Background • AVERROES • Aspirin vsapixaban • AF/risk factor • 40% discontinued warfarin/60% “ineligible” • CHADS2 2.1 • Terminated – superiority apixaban • APPRAISE • ACS • DAPT • Terminated • Lack of efficacy • Excess bleeding

  6. Randomised non inferiority • 18,201 patients • 1034 in 39 countries • Apixaban 5mg bdvswarfarin (INR 2-3) • AF plus one risk factor • 70% excreted faeces • Issue renal impairment • Dagibatran

  7. ARISTOTLE • Median follow up 1.8 years • Primary outcome • Stroke/systemic embolisation • 1.27% vs 1.6% • HR 0.79; p<0.001 for non inferiority • Death • 3.52% vs 3.94%; p=ns • Haemorrhagic stroke • 0.24% vs 0.47% • HR 0.51; p<0.001 • Ischaemic stroke • 0.97% vs 1.05%; p=ns

  8. ARISTOTLE • Major bleeding • 327 apixabanvs 462 warfarin • Conclusion • 1000 patients treated • Prevent six strokes • 15 major bleeds • 8 deaths

  9. ENGAGE AF • Satellite symposia • 90 minutes….. • Edoxaban • Completed enrollment • Event driven trial • Two doses • Ability to adjust according to change in weight/Cr • Incorporate

  10. Beyond AF • Factor Xa inhibitors • Rivaroxaban ACS • RUBY 1 • Darexaban • EHJ • Multicentre, double blind phase II dose finding study • Stabilised ACS • 1279 patients • One of six doses • Bleeding end point • Dose dependent increase in bleeding compared to placebo • No difference secondary end point – incorporating death/MI

  11. CORP • Colchicinevs placebo • Annals Internal Medicine • ESC Guidelines Class I • Four Italian centres • 120 patients recurrent pericarditis • Conventional treatment (Aspirin/NSAIDs) vs conventional treatment and colchicine (1-2mg daily for 24 hours then 0.5-1mg daily for six months)

  12. CORP • 18 months • Recurrence • 24% colchicine group vs 55% placebo • Symptom persistence at 72 hours • 23.3% vs 53.3% • No safety differences/drug withdrawal • Small • Reinforces previously published data (CORE/COPE)

  13. Angry (Cardiologists)…. • Abstract • Pisa, Italy • 228 patients post MI • Complete questionaires • Anger • Cattells Sixteen Personality Factors Questionaire • Stress related disturbance • Psy-inventory scales • Followed for median 97 months

  14. Subjects with high anger scores • 2.3 fold risk of new event • High stress scores • 1.9 fold higher risk • As a prognostic determinant, anger measures outweigh LVEF, lipids and heart rate variability • Ongoing research • Treatment to learn self management for behavioural change

  15. SHIFT Echo Substudy • SHIFT ESC 2010 • 6500 patients • LVEF <35%/clinical heart failure • Ivabradine 5mg bd or placebo to usual treatment with elevated heart rates • 18% RRR for combined end point CV death/hospitalisation • Substudy • EHJ • Echo • Quality of life • 611 patients • 304 ivabradine

  16. SHIFT Echo Substudy • Primary end point • Change in LVESVi between baseline and eight months • LVESVi reduced by 13mL vs no change in placebo • Improvements LVEF noted • Advantage • Biventricular pacing • Sinus rhythm

  17. RESET • Fascinating….. • All comers trial • Japan • Angiographic substudy • SES vs EES • Pointless • Xience V – worldwide…. • 3197 patients • SES 1567 vs EES 1600 • TLR • 571 substudy • Angiography 8 months • In segment late loss/angiographic restenosis

  18. RESET • TLR • Low • 4.3% vs 5.0% (p<0.0001 non inferiority) • In segment loss/in stent – No difference • Clinical subgroups • Age • Haemodialysis • Diabetic • Insulin • Trend….x2 • EES • Subgroup - SYNTAX

  19. More EES Action… • Alleviate concerns….. • Frightfully worried about loss of SES • Bern-Rotterdam cohort study • Superior EES • Address VLST (ie > 12 months post implantation) • Total 12339 • 4212 EES vs 3819 SES vs 4308 PES • Follow up >95% • Cumulative follow up – four years • 0.6% EES vs 1.6% SES vs 2.4% PES • Benefit greater (ie curves diverge) after one year

  20. PRODIGY • Duration DAPT after PCI • Six months vs 24 months • Guidelines 12 months • Ferrara, Italy • Multicentre study • 2000 patients • Elective/emergent PCI • Complex randomisation process…

  21. PRODIGY • EES vs ZES vs PES vs BMS • 30 days • Randomised to 6 vs 24 months clopidogrel • Primary end point • Death/MI or stroke • 10.1% (24month) vs 10% (6 month) • Bleeding • BARC classification • HR 2.17

  22. CRISP AMI • Nonsense • Randomised study IABP vs usual therapy in acute anterior AMI • Animal data prior IABP reduces infarct size/myocardial salvage • Before….. • Door to balloon/aspiration? • Surgeons hoarding….

  23. CRISP AMI • IABP 161 vs Standard 176 • Mean infarct size • %LV mass by MRI • 42.1% IABP vs 37.5% • No difference bleeding/vascular complications/ need for transfusion at 30 days • Not routine • Small • Safety

  24. Chocolate Meta Analysis • BMJ • Possible benefits chocolate consumption • Antioxidant/inflammatory/hypertensive/ thrombotic • Endothelial function • Insulin sensitivity • Seven studies • 100,000 participants • Compared high vs low consumption

  25. Chocolate Meta Analysis • Results • 37% decrease in CVD • 29% decrease risk stroke • No association heart failure • Importantly • No differentiation between chocolate type • Caution re caloric intake

  26. OAT • Two OAT related notes • Practice • US Data • No change in practice • Guilty • “I don’t want to believe” • Late follow up • Unable to publish • OAT NEJM • TOSCA – II - Circulation • No change in survival • DES better vs BMS

  27. ASCOT • EHJ • Follow up lipid lowering arm ASCOT study • Completed 8 years ago • All cause mortality lower in treatment group • Most on statins • Non CV death • Hypothesis • Death from infection • “Hypothesis that there remains a longer term legacy effect”

  28. In Summary • Excellent meeting • Superb food, wine and company • Long flight • Oral anticoagulation landscape • Changing • Incorporate new data/agents • Interest

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