Introduction
Professor Richard Hobbs, Chairman of the European Primary Care Cardiovascular Society (EPCCS), offered a warm welcome to over 400 delegates from across Europe to the third annual scientific meeting in Lisbon, Portugal.
Hypertension and Stroke Masterclass
Preventing Stroke in Atrial Fibrillation:
How to assess patient risk and how to treat?
‘Atrial fibrillation (AF) is a perverse consequence of success’ said Professor Richard Hobbs (Birmingham, UK) in describing how an ageing population and improved survival from coronary heart disease is resulting in an increasingly large cohort of patients with AF. There is a five fold increased risk of stroke for patients with AF and they are also at risk of multiple strokes and more severe strokes. This has major implications for patients, their families and healthcare systems.
There is a large body of evidence to support the use of antithrombotic agents in patients with AF to reduce stroke risk. ‘Warfarin is one of the most effective treatments we have in medicine’, said Professor Hobbs. The large treatment effect of warfarin in terms of reducing stroke risk must however be balanced against the risk of major bleeding. Risk stratification scores such as CHADS2 can be used to determine which patients should be offered warfarin rather than aspirin however many fall into the intermediate category. CHADS2 VASC is a more accurate tool which incorporates advanced age, sex and history of coronary artery disease in addition to the original score components.
The importance of considering treatment in the elderly was also discussed. ‘The average life expectancy age 65 is over 20 years….which means there is plenty of time for preventative strategies to be beneficial’ The results of the BAFTA study showed patients with AF over 75 years of age treated with warfarin had a significantly reduced risk of stroke compared to those treated with aspirin without an increased risk of major haemorrhage. However, warfarin does have a narrow therapeutic window and requires frequent dose adjustments so the recent evidence from the RE-LY study in favour of the direct thrombin inhibitor Dabigatran is encouraging. Unlike warfarin, direct thrombin inhibitors act at a single point on the coagulation.
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What’s new in Hypertension?
‘Hypertension is not a boring subject…high blood pressure remains a common cause of morbidity and mortality across Europe due to stroke, heart failure and renal disease’, said Dr Thierry Christiaens (Gent, Belgium). He went on to highlight recent advances in hypertension research such as self-monitoring, non-drug treatment and randomised controlled trials which had looking at drug combinations and the effect of tighter blood pressure control.
The TASMINH2 study recently published in the Lancet took patients aged 35-85 years with a blood pressure above 140/90 despite initial antihypertensive treatment and randomised them to self monitor blood pressure and self titrate antihypertensive medications or to usual care. At six months, systolic blood pressure was 3.7mmHg lower and at 12 months was 5.4mmHg lower in the intervention compared to the control group. However only a small proportion of participants invited agreed to take part in the study which could mean that this method of blood pressure control is only suited to a particular group of the population. ‘Those who are more socially deprived may be less successful in this approach’ said Dr Christiaens.
Non drug treatments for hypertension include the Dietary Approaches to Stop Hypetension (DASH) diet which is rich in fruits, vegetables, low fat dairy and reduced fat and cholesterol. Patients following the DASH diet have a significantly lower blood pressure compared to those on a usual diet. Dr Christiaens also reviewed the results of some large randomised controlled trials investigating optimal blood pressure control. The ACCOMPLISH study compared antihypertensive combinations in diabetic patients with hypertension. Patients treated with benazepril and amlodipine had significantly lower rates of the composite primary end point (myocardial infarction, stroke, revascularisation, hospitalisation and death) compared to those receiving benazepril and hydrochlorothiazide suggesting a possible beneficial effect of calcium channel blockers over thiazides when used in combination with an ACE inhibitor. He also discussed the issue of achieving tighter blood pressure control in high risk patients and the results of the ACCORD and INVEST trials which suggested a target of a systolic blood pressure below 130 mmHg may be harmful in this group.
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Transient Ischaemic Attacks: How to diagnose and what to do?
Transient ischaemic attack (TIA) is a sudden focal neurological deficit that lasts less than 24 hours. It requires acute assessment and if the symptoms and signs have not fully resolved at the time of consultation, the patient should be treated as if they are having a stroke. Patients with TIA have a 5.2% risk of having a stroke in the first week after TIA and require urgent assessment and modification of risk factors. ‘Time is key’ said Professor Richard McManus (Birmingham, UK). The ABCD2 score can be used to decide how rapidly patients need to be seen in a specialist clinic.
A score or four or more means the patient should be seen as soon as possible, and at least within 24 hours, by a stroke specialist. Those with a score of less than four should be seen within one week. However there is evidence that many patients with symptoms of TIA may wait to see their GP rather than accessing emergency medical care which can introduce a delay in treatment. Professor McManus reviewed the evidence for secondary prevention in patients with a history of TIA or stroke. The European Stroke Prevention Study 2 showed a reduced rate of recurrent stroke over two years in those receiving a combination of aspirin and dipyridamole. The PROGRESS trial showed a beneficial effect of perindopril and hydrochlorothiazide in reducing blood pressure and risk of recurrent stroke and overall cardiovascular mortality in patients with previous TIA or stroke. Anticoagulation in patients with atrial fibrillation over the age of 75 was supported by the findings of the BAFTA study which showed a reduced stroke risk with no increase in major adverse effects compared to aspirin. Carotid endarterectomy is also beneficial in patients with more than 70% stenosis and should be carried out within two weeks of TIA. ‘Time really is the key’, Prof McManus emphasised.
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Arrhythmias – Which are important and what can you do?
Arrhythmias can be difficult to diagnose in primary care. Dr Frans Rutten (Utrecht, Netherlands) suggested the reasons why GPs find it challenging to manage arrhythmias could be due to the uncertain predictive value of symptoms, the paroxysmal nature of arrhythmias and that an ECG taken at the time of the arrhythmia and accurate interpretation is required for diagnosis. He reviewed the common symptoms and signs of arrhythmias and used the rest of the seminar to review the ‘most common and sustained cardiac arrhythmia’; atrial fibrillation (AF). AF affects 1-2% of the general population and over 10% of people over the age of 80. It is associated with a five fold increased risk of stroke, increased mortality, hospitalisation and reduced quality of life. The importance of checking the pulse was emphasised. ‘As GPs we should always be alert for AF…..so check the pulses of patients over the age of 65 seen in clinic’, said Dr Rutten. The role of rate and rhythm controlling agents was also addressed. ‘The use of rhythm control agents in achieving sinus rhythm needs to be weighed against their proarrhythmic effects and adverse event profile
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Heart Failure Masterclass
What’s new in diagnosis: Is there a clear diagnostic pathway?
Heart failure can present with non-specific symptoms such as fatigue or reduced exercise tolerance. ‘Patients in primary care are more likely to be elderly with multiple comorbidities and gradual onset of symptoms is more common’, said Dr Frans Rutten (Utrecht, Netherlands). ‘Patients with acute onset breathlessness are more likely to present to the emergency department’. The European Society of Cardiology guidelines on diagnosis and management of heart failure recognise this distinction. ECG, chest–xray and natriuretic peptides can help in ruling out a diagnosis of heart failure however echocardiogram remains the most commonly used investigation for making a definitive diagnosis of heart failure in clinical practice. ‘Can a diagnostic and treatment pathway be solely in the hands of the primary care physician?’ asked one delegate. ‘GPs are more able than they think they are……if heart failure is slow in onset and there are no reversible causes, then there is no reason why GPs cannot manage the patient’, said Dr Rutten. Primary care is well placed to carefully manage the interplay between co-morbidity and compliance. Co-morbidities make diagnosis more difficult, worsen prognosis and limit therapeutic options. As generalists GPs are used to dealing with these challenges.
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Co-morbidities in heart failure and improving concordance with treatments
‘One in five patients with COPD has unrecognised heart failure and between one in five and one in ten patients with heart failure has COPD’, said Prof Arno Hoes (Utrecht, Netherlands) in describing the challenge of co-morbidities faced by GPs. The prognosis of patients with both heart failure and COPD is significantly worse than with either disease alone. The old dogma that B blockers should not be used in patients with COPD was also challenged. ‘Selective B blockers do not affect lung function in COPD patients without evidence of reversibility’. B blockers should be considered for patients with heart failure to improve functional status and prognosis. The importance of encouraging compliance in patients with heart failure was also considered. Resources such as heartfailurematters.org can be useful sources of information for patients, families and their carers
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Cardiovascular Disease Prevention Masterclass
Should we treat lifetime risk in CVD prevention?
‘Coronary heart disease, despite a decrease in mortality over recent years, remains a major cause of morbidity and mortality across the world’, said Dr Peter Lansberg (Amsterdam, Netherlands). It is fifty years since the original work in the Framingham cohort which identified risk factors associated with cardiovascular disease (CVD). The INTERHEART study found that 90% of population attributable risk of myocardial infarction can be explained by nine risk factors. Targeting individuals at high risk alone is unlikely to reduce the overall prevalence of CVD. Population based approaches are also required if the CVD burden is to truly be addressed. Risk scores in use currently include Framingham (a white US population), SCORE (European) and Q Risk (from routinely collected GP data in the UK). Each scoring system has limitations, for example, Framingham is poor at predicting risk in women and non-white patients.
Dr Lansberg went on to discuss the concept of lifetime risk. Multiple risk factors at a young age can lead to subclinical atherosclerosis then CVD however most risk scores rely heavily on age as a key element to determine treatment threshold. ‘If we wait until the patient reaches the age at which the threshold for treatment stands, atherosclerosis will already be established’. The importance of aggressively treating lifestyle factors at all ages is paramount. A population approach is required to tackle risk factors such as high fat intake and obesity. Measures such as increasing tax on high calorie, high fat food may help to discourage poor eating habits. The shift in societal attitudes towards smoking could also be seen for unhealthy eating. Delegates were also given a challenge to ‘Practice what we preach’ by setting an example to our patients by eating healthily and taking regular physical exercise.
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Do Cardiac biomarkers or tests add value to CVD risk prediction?
There are multiple biomarkers available in research settings and clinical practice. Measurement of biomarkers can be important to determine cause, aetiology and prognosis in many diseases. In CVD risk prediction, accurate estimation of risk is essential in order to targeting interventions at those who would most benefit. The place of biomarkers is in improving accuracy of risk prediction. Biomarkers can be useful to predict development of CVD but will not necessarily explain the mechanism of disease. ‘Risk prediction tools are just tool’, said Professor Arno Hoes (Utrecht, Netherlands). The plethora of biomarkers which have come to market in recent years have shown disappointing results overall in terms of improvement in risk prediction. ‘Evidence of CRP in predicting CVD risk is not good enough to justify doing the test in everyday practice’ said Professor Hoes.
‘Cardiovascular risk profiling is becoming increasingly important and better tools are needed to allow clinicians to identify which patients should receive preventative therapies. Accurate prediction is the essence of risk scoring’.
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Diabetes Masterclass
What should glycaemic and blood pressure targets be?
‘This week we have seen the death of Rosiglitazone’, said Dr Neil Munro ((Esher, UK) after European regulators recommended withdrawal of the drug due to increased concerns about cardiovascular safety. The management of Type II diabetes remains a challenge for primary care physicians. A range of drugs with different mechanisms of action are available to clinicians but what targets of glycaemic control should we be aiming towards? The UKPDS trial showed a beneficial effect of improving blood pressure control in reducing microvascular complications but this was not seen for macrovascular complications during the study. However, a ‘legacy effect’ was seen after the initial phase of the trial completed with reduced rates of myocardial infarction and death in the group with more intensive blood glucose control. So is a ‘the lower the better’ approach justifiable in clinical practice and is it safe? The ACCORD study has recently cast doubt on the safety of a very intensive approach to blood glucose lowering. Patients who were treated to a target HbA1c of 6% had a significantly increased mortality compared to those with less tight blood glucose control and the trial was stopped early. Observational data of the relationship between HbA1c and survival suggests an optimal HbA1c of 7-7.5%.
Multifactorial intervention in diabetes has been shown to be effective in patients with type II diabetes. In the STENO-2 study, patients were randomised to receive an intensified multifactorial intervention or standard therapy. The intensified multifactorial intervention included tight glucose control and use of aspirin, lipid lowering agents and renin-angiotensin system blockers. There was a significant reduction in cardiovascular mortality and microvascular complications in the group which was intensively treated. The ADDITION study is also investigating the role of intensified multifactorial intervention in patients with type II diabetes detected by screening.
Blood pressure control in addition to adequate glycaemic control is also important to reduce diabetic complications but the optimal blood pressure target is not known. Is ‘the lower the better’ justifiable? The INVEST study included patients over 50 years of age with diabetes and coronary heart disease and randomised patients to a target systolic blood pressure of less than 130mmHg, 130-140mmHg (usual care) or >140mmHg. There was an increased mortality seen in the group treated to a target of less than 130 systolic during the extended follow-up period compared with the usual care group suggesting a target of 130-140mmHg may be optimal in patients with diabetes and coronary heart disease.
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Should HDL and TGs be targeted in diabetes?
‘There is a high incidence of dyslipidaemia in the diabetic population’ Dr Peter Lansberg (Amsterdam, Netherlands) reminded delegates. The MR FIT study showed cholesterol levels were directly proportional to CVD mortality in male patients with diabetes. Low levels of HDL and high levels of triglycerides and LDL is a pattern commonly seen in diabetic patients. Lipids levels appear to have an increased effect on CVD mortality in diabetic compared to non-diabetic patients. The UKPDS study showed LDL-C was a strong predictor of coronary heart disease. Patients with diabetes have an accelerated pattern of atherosclerosis which may be due to smaller LDL particles which are more easily taken up by the vascular wall. Increased ApoB levels are also seen as apart of the metabolic syndrome. A range of guidance for lipid lowering is seen in different countries. American and Canadian guidelines include ApoB targets. Statins reduce lipid levels but there is likely to be a residual risk. There has been renewed interest in drugs such as nicotinic acid which can increase HDL levels. ‘It is likely that we will be using a combination of drugs to achieve lower lipid levels in the future’, said Dr Lansberg. Weight loss and exercise can also reduce triglycerides. Dr Lansberg completed his talk with an inspiring story of a patient with diabetes who took a four month back packing trip which led to a dramatic improvement in his lipid profile and glycemic control.
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What role do newer agents have in diabetes in the community?
Dr Munro followed on from his first talk about glycaemic and blood pressure targets in diabetes by highlighting the risks associated with obesity and diabetes beyond cardiovascular disease. ‘Cancer is a major cause of death in patients with type II diabetes’, he said. Thirty one per cent of deaths in patients with diabetes are due to cardiovascular disease but 29% are due to cancer. Increased body mass index (BMI) is associated with an increased risk of cancer. Type II diabetes is associated with hyperinsulinaemia in the initial phases of the disease. Insulin has a mitogenic action and insulin growth factor – 1 is associated with increased cancer cell expression. Hyperglycaemia also promotes abnormal cell growth. Metformin has been shown to have a protective effect against cancer.
New agents such as the gliptins (dipeptidylpeptidase-4 inhibitors) and glucagon-like peptide–1 (GLP-1) agonists are improving the range of options available to clinicians treating patients with diabetes. New delivery systems which allow nasal, sublingual and buccal administration of insulin also look promising. In addition, once weekly insulin regimes such as Degludec are currently undergoing evaluation and may in the future reduce the burden of daily injections and monitoring in patients with diabetes requiring insulin.
The link between the gut and obesity needs to be better understood in order to provide therapeutic options. Mice experiments have shown that transplanting the bowel contents of a thin mouse into an obese (ob/ob) mouse results in the obese mouse becoming thin. ‘Theories around gut microbiota have been used to explain these findings’, said Dr Munro
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Plenary lecture
Venous Thromboembolism and Pulmonary Embolism: The Forgotten High Risk Disease
Venous Thromboembolism (VTE) is a major cause of death which can be forgotten by many clinicians. ‘We are not good at diagnosing VTE before or after death’, said Professor David Fitzmaurice (Birmingham, UK). The risks of VTE are also not well known to patients except in relation to air travel. VTE is the leading cause of cardiovascular mortality after coronary heart disease and stroke. It kills more people in the UK than HIV, breast cancer, prostate cancer and road traffic accidents put together. However effective preventive strategies such as compression stockings and low molecular weight heparin (LMWH) can reduce the morbidity and mortality associated with this important disease. Randomised controlled trials such as MEDENOX, PREVENT and ARTEMIS have shown that prophylaxis with blood thinning agents is effective in reducing the risk of VTE without a significant increased bleeding risk.
The American College of Chest Physicians and others have published clear guidelines which advocate the widespread use of LMWH in VTE prevention. There has been a decrease in VTE in surgical patients in the past 40 years but this has not been seen for medical patients who make up over 60% of hospital admissions. The ENDORSE study was a multinational cross-sectional survey which examine patients in hospital wards in 32 countries and assessed which patients were at risk of VTE and which patients were receiving VTE prophylaxis. Fifty two per cent of patients were at risk of VTE but only 50% of those at risk were receiving appropriate treatment demonstrating the underuse of evidence based treatments to prevent clots across the world. All patients admitted to hospital in the UK should now undergo a VTE risk assessment and payment to hospitals is partly based on reaching a target of 90% of patients being risk assessed.
Professor Fitzmaurice emphasised the role of primary care in having an increased index of suspicion for VTE, educating patients about the importance of risk assessment, ensuring implementation of extended thromboprophylaxis (e.g. following hip of knee surgery) and a potential future role of carrying out risk assessment in the community.
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Freestanding abstract presentations from EPCCS members
The conference welcomed abstract presentations from EPCCS members for the first time.
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Workshop Sessions
Conference delegates were invited to attend parallel workshop sessions which included:
1. How to read an ECG after a 30 minute workshop.
2. How to assess vascular risk and use CV risk calculators.
3. How to measure ankle-brachial pressure index.
4. Clinical care studies decision analysis.
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