Day One
By Dr Noor Sharrack, Cardiology SpR
With public gatherings banned in the Netherlands due to the COVID-19 pandemic, the 2020 edition of the European Society of Cardiology Congress, originally due to take place in Amsterdam, was staged online from 29 August to 1 September. BCS members in attendance share their experience of the first day of this new format. Read the full article…
Professor Barbara Casadei nicely opened the conference in her inaugural lecture with a stark reminder of the importance of unity and collaboration in the era of COVID-19. She reminded us of the great research being undertaken by our colleagues across the globe and the toll this pandemic has taken on our patients. The first day presented the results of 2 important trial results, EMPEROR-Reduced and EXPLORER-HCM both of which have been published in the NEJM.
EMPEROR-Reduced
Milton Packer presented the results of EMPEROR-Reduced recently published in the NEJM. 3730 patients were randomised to either empaglifozin 10mg (n=1863) or placebo (1867). All patients were receiving optimal medical treatment for heart failure. All 3 endpoints were reached with statistical significance. The primary outcome of cardiovascular death, or HF hospitalisation for empaglifozin vs placebo was 19.4% vs. 24.7% (hazard ratio 0.75, CI 0.65-10.86, P<0.001. Second endpoint was total heart failure hospitalisations and the third was slope of decline in glomerular filtration rate over time.
Compared to DAPA-HF, this study enrolled patients with lower ejection fractions and worsening renal function. 70% of patients enrolled had an ejection fraction <30%.
The 25% decrease in the risk of the composite of cardiovascular death and heart failure hospitalisations was identical to that seen in DAPA-HF. Empaglifozin also slowed down the decline of renal disease.
EXPLORER-HCM
In the EXPLORER-HCM global phase 3 trial, 251 patients with symptomatic obstructive HCM were randomised to once-daily mavacamten (5 mg initially with a two-step dose titration) or placebo for 30 weeks. Mavacamten is a selective allosteric inhibitor of cardiac myosin ATPase designed to target fundamental abnormalities associated with HCM.
The primary endpoint was the treatment effect of mavacamten at week 30 relative to placebo on both symptoms and cardiac function, defined as achieving 1) ≥1.5 mL/kg/min improvement in peak oxygen consumption (peak VO2) and ≥1 New York Heart Association (NYHA) class reduction or 2) ≥3.0 mL/kg/min improvement in peak VO2 and no worsening of NYHA class.
EXPLORER-HCM demonstrated the efficacy of mavacamten in obstructive HCM. Primary and all secondary endpoints were met with high statistical significance. At week 30, 45 (36.6%) patients on mavacamten met the primary endpoint vs. 22 (17.2%) patients on placebo (p=0.0005).
Mavacamtem demonstrated clinically important effects on post-exercise LVOT gradients. Nearly 75% of patients saw a reduction below guideline-defined thresholds for invasive septal reduction therapy (SRT) and 56% showed complete relief of obstruction. Mavecemten was well tolerated with a safety profile comparable to placebo.
Image Guided Care in Heart Failure – Meet the Experts
Professor James Thomas from Northwestern University in Chicago presented an interesting case of cardiac sarcoidosis. He recalled the heterogeneity of presentation in this condition; heart block, A/V arrhythmias, HFrEF, HpPEF, sudden cardiac death. A number of imaging modalities helped clinch the diagnosis; echo, cardiac MRI and FDG-PET. ECHO can show non-specific findings, such as regional wall motion abnormalities in a non coronary artery distribution, reduced ejection fraction, diastolic dysfunction, and secondary pulmonary affects from pulmonary sarcoid such as RVH and RV dysfunction.
In acute cardiac sarcoidosis with inflammation of the heart, CMR can show oedema, early Gd enhancement and increased intensity on T2 weighted imaging. Later stages show fibrosis in a non-coronary artery distribution, Gd enhancement in the mid wall and epicardial regions.
He reminded us of FDG-PET scanning as one of the most specific tests in diagnosing sarcoidosis and helped monitor the treatment of sarcoidosis with steroids.
Phillipe Meyer, from Belgium, presented another interesting case of a patient with diastolic dysfunction with was ultimately diagnosed with cardiac amyloidosis.
In this case a variety of imaging modalities were used; echo, CMR, DPD scanning and PET-CT. Echo can show LVH, reduced longitudinal strain, apical sparing and diastolic dysfunction. CMR shows sub-endocardial enhancement of gadolinium suggestive of amyloid infiltration. He highlighted the importance of DPD bone scanning in this condition (particularly in TTR amyloid), and a haematological workup. His feeling was that if there was a negative haematological work-up, biopsy is not needed. However, if there was a positive haematology panel, biopsy would be indicated. He also illustrated PET-CT as a research method used in his centre in the diagnosis of amyloidosis to avoid biopsy.
He concluded by reminding clinicians that cardiac amyloidosis should be suspected in any patient with HfPEF and increased wall thickness. The diagnosis requires a multi-imaging approach and myocardial biopsies are rarely needed. An accurate and rapid diagnosis is crucial because specific therapies are available for AL and ATTR amyloidosis. The mid-term prognosis is poor, especially for AL amyloidosis.
Multimodality Cardiac Imaging in Clinical Practice – Essential Update
Professor James Moon from Barts and UCL talked about multimodality imaging in patients with left ventricular hypertrophy. LVH measurement is often very variable depending on who and how it is measured (with differences up to 1cm). He highlighted the new era of Artificial Intelligence, and how this will help streamline measurements of LVH.
He also talked about the under-diagnosis of TTR amyloid in the population and especially in certain groups of patients. For example, 1/8 TAVI patients have TTR amyloid. He mentioned TPD scanning as an important test. CMR in AL amyloid is crucial; LVH, LGE, T1 and ECV mapping.
Summary
This was an excellent day were two clinical trials published in the NEJM were presented. The digital experience worked very well. One was able to re-watch lectures at a later time if they had missed them and nobody struggled to find a seat! Looking forward to the next 3 days.
