September 1st, 2013
An Almost Striking Start to ESC
Several Cardiology Fellows who are attending ESC.13 in Amsterdam this week are blogging for CardioExchange. The Fellows include Paddy Barrett, Louis Handoko, and Amanda Vest. For more of our ESC.13 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our Coverage Headquarters.
Amsterdam hosts the ESC congress this year, a fantastic city which I have had the fortune to visit many times over the years. My arrival this year, however, was almost my last, due to some significant wind shear on landing at Schipol airport which brought me the closest I’ve ever been to a wing strike. Happily, I survived the landing and made it to the start of the congress.
There are two certainties at ESC each year. Firstly, I make out my schedule for the conference and promptly realize that most of my selections are running concurrently and I will disappointedly miss out on much of what I had hoped to attend. Secondly, within seconds of taking my seat I will rediscover the incredible depth and breath of content that ESC delivers every year. This year has been no different.
Another constant has been the presentation of some potentially practice-changing data. One of the first trials presented at the Hotlines session was the PRAMI trial, which looked at the treatment of non culprit lesions in acute STEMI patients. Both the European and US guidelines are clear on this point: Beyond a set of limited scenarios such as ongoing cardiogenic shock, PCI of the non-culprit lesion is not advised. This 600-patient trial, however, demonstrated a 65% risk reduction in MACE. The timing of intervention resulted in almost immediate benefit, but the primary investigator, Dr. David Wald, noted that although the guidelines are explicit in terms of the immediate management of non-culprit lesions, the management strategy of these lesions in the post-MI period is somewhat less clear. Although PRAMI is a small trial, the significant risk reduction achieved will likely heavily influence the writing of the next STEMI management guidelines.
On the basis of findings from CURE and other studies, the practice of pretreatment of patients presenting with acute coronary syndrome with a second antiplatelet drug has become a cornerstone of cardiology practice. However, the ACCOAST trial raises some provocative questions to this approach, at least with the use of prasugrel. The trial randomized NSTEMI patients to pretreatment with prasugrel or placebo in addition to standard of care. Unexpectedly, not only was there no difference in ischemic end points, there was a significant increase in bleeding events. Although patients were initially pretreated with a smaller dose of prasugrel than conventionally used (30 mg), the pharmacodynamic studies performed concurrently demonstrated effective platelet inhibition. I would have to agree with Dr George Dangas’s point that the intervention community needs to look at the positive aspects of this study in so far as the safety of giving our patients a second antiplatelet only at the time of angiography. Whether this trial will substantially influence the content of the next NSTEMI guidelines remains to be seen and will likely require some additional investigation.
Basic Science and Incredible Imaging
Beyond the presentation of novel, late-breaking findings, the congress is awash with incredible clinical and basic science content. On a personal topic of interest, the staff at University Hospital Zurich gave a fantastic overview of atherosclerotic plaque vulnerability assessment and potential for management. Our ability to identify the vulnerable plaque has improved enormously, but how to selectively manage these lesions remains uncertain. Not all plaques are vulnerable, not all vulnerable plaques rupture, and even those that lose endothelial integrity do not result in infarction. We have moved the needle here but we still have a lot to learn. What is clear is that beyond some incredible science of atherosclerotic plaque vulnerability, this is an area which produces some of the most visually pleasing imaging; OCT to me is as if Pixar got a hold of routine angiography producing some of the most stunning imagery in cardiology today.
As ever, ESC has not failed to deliver a fantastic program covering a huge range of topics. More than anything, I’m reminded of how much I enjoy the field, and excitingly, we get to be part of the evolution of our specialty. After today, we are all certainly a little wiser. Tomorrow, we will be a little bit more, and I am indeed looking forward to it.