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CardioPulse ArticlesEHJ's new deputy editor Gerhard HindricksNEW EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart diseaseThe PARTNER trial after 1 yearBook reviewStress Echocardiography: Essential Guide and DVDKing's College London, a cardiac centre of excellenceWill it only be possible to deliver the best cardiovascular medicine in ‘capital cities’ in the future?Russian Cardiology Journal celebrates its 15th anniversary this yearThe Estonian Society of CardiologyThe London Marathon debate

DOI: http://dx.doi.org/10.1093/eurheartj/ehr249 2087-2095 First published online: 1 September 2011

EHJ's new deputy editor Gerhard Hindricks

Professor Gerhard Hindricks, director of the Department of Electrophysiology Leipzig University Heart Center, Germany, became EHJ's deputy editor for electrophysiology and arrhythmias on August 1.

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G. Hendricks

He is one of the most experienced clinical electrophysiologists in catheter ablation of atrial fibrillation and ventricular tachycardia, with thousands of patients operated on.

His principal research interest relates to the mechanisms and treatment of cardiac arrhythmias, especially catheter ablation. He has worked in the field of catheter ablation for almost 30 years, from the beginning of the technique's development, and was a member of the team of scientists who performed the first radiofrequency catheter ablations worldwide in Münster, Germany, in the late 1980s.

In the 1990s, Hindricks contributed significantly to the development of radiofrequency catheter ablation on a biophysical and clinical basis. In 1992, he was the principal investigator in the Multicentre European Radiofrequency Survey which was the first survey on radiofrequency catheter ablation worldwide, summarizing data on almost 5000 patients in Europe.

In addition to catheter ablation, his research interests include electrical therapy of heart failure, with a particular focus on cardiac resynchronization therapies, and prevention of sudden cardiac death using medical and non-medical treatment modalities such as catheter ablation of ventricular tachycardia.

He heads the biggest EP department in Europe, which houses 4 catheter laboratories and 50 physicians specialized in cardiac electrophysiology that perform almost 5000 interventional procedures per year.

Hindricks has been an EHJ reader for nearly 25 years and has watched it becoming the leading cardiovascular journal in Europe and among the top 3 worldwide. ‘I would like to strengthen the role of clinical electrophysiology in the European Heart Journal to make the journal even more attractive for physicians subspecialized in electrophysiology’, he says.

Cardiac electrophysiology and catheter ablation will be the fastest growing segment in cardiovascular medicine in Europe over the next 5–10 years. He calculates a 5–7% average yearly increase in procedures and economic/scientific turnover. That means that the key centres will experience a growth of 10–12% per year and that, in 10 years, the market will be almost twice as big as it is now.

‘That has a significant impact on the European Heart Journal because there is a tremendous demand for science and education in the field and I take that very seriously in my role as deputy editor for electrophysiology’, says Hindricks. ‘I will make sure that we provide the latest scientific information, the best reviews from worldwide experts on arrhythmia research, and the best clinical views on cardiac arrhythmias that we can get, in order to improve the quality of the journal further over the next years in the field of arrhythmia research’.

He anticipates ‘an easy and fruitful’ cooperation with the EHJ team at the University of Zurich. Hindricks has discussed the duties and role of the position with former deputy editor Professor Josep Brugada, who has been a friend for decades and will provide support for the first month. He says, ‘That will give me a good and successful start’.

Jennifer Taylor, MPhil

NEW EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease

The new full and detailed recommendations later in this issue are summarized here by Jose L. Zamorano, MD, FESC, chair EAE writing group

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The introduction of devices for transcatheter aortic valve implantation (TAVI), mitral repair, and closure of prosthetic paravalvular leaks has led to a greatly expanded armamentarium of catheter-based approaches to patients with regurgitant as well as stenotic valvular disease.

Echocardiography plays an essential role in identifying patients suitable for these interventions and in providing intra-procedural monitoring. Moreover, echocardiography is the primary modality for post-procedure follow-up. The echocardiographic assessment of patients undergoing transcatheter interventions places demands on echocardiographers that differ from those of the routine evaluation of patients with native or prosthetic valvular disease. Consequently, the European Association of Echocardiography (EAE) in partnership with the American Society of Echocardiography (ASE) has developed Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease. It is intended that this document will serve as a reference for echocardiographers participating in any or all stages of new transcatheter treatments for patients with valvular heart disease. The document is really focused on the new type of interventions performed inside the cath lab. A close cooperation, and often a common ‘language’ of interpretation, between subspecialties is needed.

Transcatheter aortic valve implantation (TAVI)

Imaging is fundamental for successful TAVI. In this document, all echocardiography requirements from patient selection, through procedural guidance, to detection of early and late complications are described.

Echocardiography must determine whether the patient's anatomy is suitable for TAVI, considering the anatomic characteristics of the aortic valve and the annular dimension. The latter is a key measurement as this determines eligibility for TAVI and guides the selection of valve type and size. When transthoracic two-dimensional echocardiographic measurements of the annulus are uncertain, transoesophageal echocardiography (TEE) ± three-dimensional (3D) evaluation may be necessary, because undersizing the prosthesis can result in device migration or significant paravalvular aortic regurgitation, whereas oversizing predisposes to complications related to vascular access or to difficulties when crossing the native aortic valve with the delivery system.

Periprocedural TEE can aid balloon positioning during valvuloplasty, aid prosthesis positioning during implantation and in conjunction with fluoroscopy, confirm prosthesis function immediately post-implantation, and thereby rapidly detect complications.

Percutaneous transcatheter repair of paravalvular regurgitation

The success of transcatheter closure of paravalvular regurgitation (PVR) is limited by the anatomy of the defects which tend to be irregular and may be multiple, technical challenges in positioning closure devices, and the limitations of available devices and imaging modalities.

Echocardiography has proven essential in paravalvular leak closure with both TEE and intracardiac echocardiography used to guide these procedures. Three-dimensional TEE is now considered the preferred imaging modality as it is uniquely capable of demonstrating the location, the irregular (frequently eccentric) shape of the defects, and is better able to identify multiple defects and provide accurate sizing. Transoesophageal echocardiography may be used to guide the transseptal puncture and help to guide the passage of the guide wire and catheter through the defect and during deployment of the closure device. It helps to ensure proper positioning of the opened occluder over the paravalvular defect and proper seating of the device. After release of the device, TEE evaluates residual PVR, which is not uncommon after the procedure, when the placement of additional devices can be considered.

Percutaneous mitral valve intervention

At present, patient selection involves a consensus between the patients and treating physicians as well as agreement that the patient is anatomically eligible based on transthoracic echocardiographic and TEE findings. The determination of the mechanism of mitral regurgitation (MR) is mandatory to select patients who can benefit from percutaneous intervention and to tailor the repair strategy. Both degenerative and functional/ischaemic MR can be suitable for percutaneous valve repair through a variety of approaches including those that offer direct leaflet repair, direct or indirect annular remodelling, and ventricular remodelling. Two-dimensional echocardiography supplemented by real-time 3D imaging is also essential to guide and evaluate the effectiveness of the chosen percutaneous repair technique. Anatomic requirements for MitraClip™ implantation and the step-by-step procedural guidance with TEE are detailed. After the procedure, TEE dictates whether there is significant residual regurgitation and if the source of the residual regurgitation is amenable to correction with a second clip. Using 3D echocardiography, it is possible to observe the repaired valve en face from both atrial and ventricular perspectives, documenting the eccentricity, if any, of the dual orifices created by the device. Moreover, TEE provides a method for early detection of the potential complications of clip placement including perforation of the atrial wall, partial dehiscence of the clip and leaflet, or chordal tears.

Transcatheter intervention for valvular heart disease is a rapidly evolving field where echocardiography plays a pivotal role. These recommendations have been designed with the non-invasive cardiologist–echocardiographer in mind and they should be equally valuable to anaesthesiologists and interventionists who may become involved in imaging patients undergoing transcatheter valve procedures.

The PARTNER trial after 1 year

PARTNER trial shows equivalent mortality at 1 year but different complications for transcatheter and surgical aortic valve replacement in high-risk patients.

In January, CardioPulse ran a number of articles on the fast-moving field of transcatheter aortic valve implantation. The field continues to evolve, and the latest results from the Placement of Aortic Transcatheter Valves (PARTNER) trial were published in June.1

It was the first randomized trial comparing transcatheter therapy vs. surgery in high-risk surgical candidates. It was a non-inferiority trial with a sample size of 699 patients and primary endpoint of all-cause mortality at 1 year. At 1 year, the two therapies were essentially equivalent but there were trends that seemed to favour the transcatheter therapy in certain subgroups (women, for example). Interestingly, at 30 days, the transcatheter therapy had lower mortality than surgery.

The two therapies had different procedural hazards. There was a higher rate of strokes and vascular complications with the transcatheter therapy but surgery led to higher rates of significant bleeding and new-onset atrial fibrillation.

The higher rate of strokes has received much attention. But Prof. Martin B. Leon, MD, professor of medicine and director of the Center for Interventional Vascular Therapy, Columbia University Medical Center, and founder and chairman emeritus of the Cardiovascular Research Foundation, New York City, says: ‘I would balance that against some of the other complications that occur more commonly with surgery. You have to pick your poison in a sense’.

He adds: ‘The smaller devices widely used in Europe [and] other techniques called embolic protection devices may reduce the stroke rates’.

The sample size and event rates were too low to predict which patients are more likely to have certain complications but the data will be pooled with European data with the aim of developing predictive risk models.

Another finding was that even though at 1 year the clinical benefit was about the same—patients could do the 6 min walk test and daily lifestyle activities had improved—by 30 days, there was a more rapid recovery from the transcatheter therapy. This was expected, since surgery in older people is less well tolerated (mean age was 84). There was also a 40% reduction in intensive care unit time with the transcatheter therapy compared with surgery. ‘I wouldn't call them major endpoints but it does reflect a so-called less invasive versus an open surgical approach, particularly as it impacts elderly patients’, says Leon.

An economic analysis of all costs associated with the two therapies (in hospital and out of hospital) is also underway.

Previous PARTNER results in inoperable patients showed a dramatic mortality benefit for the transcatheter procedure.2 Leon says: ‘Certain European countries have used those data to justify reimbursement because they were so powerful’.

PARTNER 2 is already underway. This randomized clinical trial will study a smaller device in intermediate-risk patients.

Jennifer Taylor, MPhil

References

Book review

Stress Echocardiography: Essential Guide and DVD

Editors: Aleksandar N. Neskovic, Frank A. Flachskampf Publisher: Informa Healthcare ISBN 978-0-415-42224-6

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Stress echocardiography is an established cost-efficient and radiation-free option for the non-invasive assessment of coronary artery disease, myocardial contractility, and coronary flow reserve and heart valve status. Stress Echocardiography: Essential Guide and DVD edited by Aleksandar N. Neskovic and Frank A. Flachskampf and co-authored by a number of internationally undisputed experts is an updated review of the principles and practice of stress echo. The early chapters provide a comprehensive explanation of pathophysiological basis, performance, interpretation, indications, and contraindications, essential to this topic. Thereafter, the diagnostic accuracy and prognostic implication of stress-induced ischaemia and viability as well as the usefulness of different testing modalities in special settings (valvular heart disease, idiopathic dilated cardiomyopathy and non-cardiac surgery) are clearly detailed. The advantages, drawbacks, and pitfalls of stress echocardiography are discussed in comparison to myocardial perfusion scintigraphy, thus providing interesting clues for the appropriate use of these competing techniques in clinical practice. In addition, a dedicated chapter provides a list of topics with a commentary of the most relevant publications in the field. A great number of illustrations, graphs, and tables allow quick and easy reference to the appropriate information. Finally, many high-quality video clips included in a DVD help to contextualize the theoretical concepts. In my opinion, this book provides an excellent guide to cardiologists who are new to the field of stress echocardiography, while representing an excellent reference source for all those interested in extending their clinical and scientific knowledge in the field.

Lauro Cortigiani, MD, Head of Echo Lab, Hospital of Lucca, Lucca, Italy

King's College London, a cardiac centre of excellence

Will it only be possible to deliver the best cardiovascular medicine in ‘capital cities’ in the future?

New developments at King's College, London, suggest that the complexity of modern cardiovascular medicine, and the enormous prospects for future advances, means that smaller cities will find it hard to compete, reports Barry Shurlock, MA, PhD

There is no doubt that Professor Ajay Shah MD, FMedSci, FESC, who is the leading cardiologist at King's College, London, has great ambitions for cardiovascular medicine at his institution, which claims to be the largest centre for the education of health-care professionals in Europe. All manner of league tables put it among the leading universities in the UK and it has more Medical Research Centres (the British body that funds national research) than any other place. It was at King's that New Zealander Maurice Wilkins worked on X-ray diffraction, and where Rosalind Franklin and Raymond Gosling obtained the crucial images that were to support Crick and Watson's structure for DNA.

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Ajay Shah

Not only does Shah want ‘King's’ to offer the very latest treatments and provide the most stimulating environment for research, but he also wants it to become a name that stands alongside others, such as ‘Mayo’, ‘Harvard’, and ‘Hopkins’. He said: ‘My vision is that King's will become a brand—so that if someone says “King's” the patient can be sure of getting the very best—that it becomes known as the place that can offer the latest state-of-the-art techniques. We aim to be THE place that people come to when want the best in heart treatment, research or teaching’.

In fact, ‘King's’ is shorthand for King's Health Partners (KHP), an amalgam of related, co-managed academic medical facilities and medical school that came together in March 2009, to include 7 hospitals and 150 community-based units. It has an annual turnover of about £2 billion (€2.5 billion) and serves a population of 5 million people. It stretches across south London, encompassing the campuses of the National Health Service trusts associated with the former standalone medical schools of St Thomas' and Guy's, as well as King's College itself.

The model that has been implemented at King's is not particularly novel in an international context, but its scale is impressive and helps to secure its place as one of the top few centres in the UK for cardiovascular medicine. At its heart is the ‘bench to bedside’ motto, so that clinicians with active research programmes can quickly translate new ideas from the laboratory to the clinic, interacting along the way with internationally distinguished researchers from a range of other disciplines. It has led to an interlocking structure of clinical and research institutions that all lead in the direction of translational research carried out alongside routine clinical responsibilities.

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Sir James Black Centre

KHP is one of five academic health science centres (AHSCs) set up 2 years ago (2009) by the British government after competitive bidding (the others are at Imperial College London, University College London, Cambridge and Manchester), with the aim of maximizing translational research effort and output. The Cardiovascular Clinical Academic Group (CAG) of KHP, which spans the King's and St Thomas's campuses, is co-directed by interventional cardiologist Dr Martyn Thomas and Prof. Shah who explained: ‘There are several reasons why AHSCs have been created. It was realised that it's better to concentrate resources in this way, with the expectation that integration might bring in more money for health care and research from industry. And we believe that this is a model that drives up quality, with better academic outputs. We believe we were chosen, competitively, because we had a relevant critical mass [of research and clinical facilities] and the appropriate infrastructure and organisational framework, with a very strong cardiovascular science base, as well as basic science, and all the necessary clinical skills. It's a complex mix, but exciting!’.

Prof. Shah, who has held the BHF Chair of Cardiology at King's since 1999, has a major research interest in NADPH oxidases in cardiac hypertrophy, heart failure, and endothelial dysfunction. As well as co-directing the CAG, he also leads the British Heart Foundation (BHF) Centre of Excellence at King's, one of only four in the UK (the others are at Imperial College London, Oxford and Edinburgh), which is based on several sites and was set up in April 2008. It includes about 250 basic and clinical researchers, not only with a cardiovascular background, but also from other disciplines such as biophysics, bioinformatics, chemistry, and imaging. It has been funded with a grant of £9 million (€10 million) over 6 years. Shah himself is based at the James Black Centre, a newly constructed research facility at King's College Hospital, named after the King's alumnus who discovered β-blockers. He recalls: ‘Jim [Sir James Black] was one of the most remarkable people I've ever met. He had an office in the building and until his death last year he used to come in every morning and spend the time reading scientific articles and writing papers. He was very keen to talk to PhD students, and if they didn't visit him he would drag them in to talk!’.

One of the areas that King's has invested in heavily is cardiovascular imaging, led by Prof. Reza Razavi. As well as clinical academic staff, it has, for example, university chairs in magnetic resonance physics, imaging chemistry, and computational modelling. This means that many patients at King's benefit from emerging techniques that are not available anywhere else. Outlining facilities in several other areas encompassed by KHP, Shah said: ‘We have numerous interventional cardiologists, so we are able to afford to have sub-subspecialists in, for example, transaortic valve implantations (TAVIs). As a result we are leading a number of European trials of newer devices. We were the first in the country to offer primary angioplasty to all patients with heart attacks and our programme is beginning to serve as a substrate for research, with several principal investigators interested in cardioprotection’.

‘We also have fantastic imaging facilities with CT, MR and PET to look at endpoints in a variety of cardiovascular studies. And there is a longstanding interest in MRI guided intervention in electrophysiology. Procedures for ablation, for example, can be very complex and to reduce the time patients spend under x-rays the aim is to derive computational algorithms, based on large data sets, to enable the clinician to better plan treatment. We also have an excellent proteomics centre, looking at new biomarkers for diagnosis and the prediction of risk in the cardiovascular field. We are trying to develop new biomarkers starting from protein characterisation in cardiac tissues and taking it forward to blood samples from patients. We have several biomarkers at the stage where we might be able to test them. [These techniques]are also helping in other areas, for example the better identification of stem cells’.

It has taken a long time for King's to get where it is, recalled Shah, who added: ‘We first started to organise and integrate cardiovascular research about 10–12 years ago, and we can see now that the arrangements we have put in place with KHP are working, and are going to generate real benefits. This is not about boxes—there, for example, is a lot of crosstalk between the BHF Centre and KHP—but it's about getting the right people interacting in an interdisciplinary way and giving them the resources. Also, although it is obviously difficult to do what we are doing on a small scale, the ultimate aim is to develop treatments and techniques that are widely applicable even in smaller centres’.

Russian Cardiology Journal celebrates its 15th anniversary this year

With 6 issues per year since its inception, next year Russian Cardiology Journal will double its issue number to 12

Russian Cardiology Journal was founded in 1996 as the official mass media of the Russian Society of Cardiologists. ‘This year we celebrate the 15th anniversary’, says Editor-in-chief Professor Victor A. Lusov.

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Russian Cardiology Journal 15-year Jubilee issue cover

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V.A. Lusov

Lusov was the founder of the journal and has been the only editor-in-chief so far. He took up the post when he was President of the Russian Society of Cardiologists. Lusov was the first president of the Society and today is Honorary President.

The journal primarily publishes original articles and reviews. It also publishes opinion and discussion papers. Authors come from Russia and the Commonwealth of Independent States (CIS) including Uzbekistan, Kazakhstan, and the Republic of Belarus.

In Russia and the CIS area, the Russian State Attestation Commission registers scientific work completed for scientific degrees (PhD or DrSc) and awards these degrees. The commission only recognizes articles that are printed in a specific list of journals. Russian Cardiology Journal is on this list and so prints articles written by students in Russia and the CIS area.

Each issue holds up to 20 articles and is 100–120 pages in total. Every year the journal receives up to 200 manuscripts. In around 15–20% of cases, the papers are rejected or authors are asked to make modifications and resubmit the article. It takes 6–12 months to publish articles and there are currently nearly 80 manuscripts awaiting printing.

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Dr Evgeny O. Taratukhin

The journal's impact factor is 0.164. ‘We try to get better and to publish more modern articles and have a higher subscription’, says the journal's responsible secretary, cardiologist Dr Evgeny O. Taratukhin. ‘Our subscription is not expensive and we do not have too many advertising articles’.

The journal is mainly aimed at practicing cardiologists and scientists, but the audience also includes internal medicine physicians. Members of the Russian Society of Cardiologists receive the journal. The Society publishes a second journal called Cardiovascular Therapy and Prophylaxis.

Russian Cardiology Journal is published in Russian and abstracts are also translated into English. It is available online in the Scientific Electronic Library (http://www.elibrary.ru/), the Russian Index of Scientific Citation. ‘Subscriptions from foreign countries are also possible with this site by email address’, says Taratukhin.

The journal's editorial office is in Moscow. The core editorial team consists of four people. In addition to Lusov, Editor-in-Chief, and Taratukhin, Responsible Secretary, it includes a Vice-Editor-in-Chief and a Responsible Editor—all with a medical education and scientific degrees.

The journal also has a group of professors of medicine from different institutions who review the manuscripts for scientific quality, ethical issues, and quality of literature used for reviews. Most professors are from Russia and the CIS area but some originate from the USA, Germany, Switzerland, Bulgaria, and the Czech Republic.

The journal launched with six issues per year and has continued with that number. But the main goal for the future is to increase the number of issues and discussions are underway with the publisher. ‘It's not so simple to do this, but we have enough articles so we can do it’, says Taratukhin.

Lusov is confident that as of next year, Russian Cardiology Journal will have 12 issues each year. He says: ‘The main task is to keep and improve quality of articles—because it means quality scientific work’.

The journal is currently published in black and white and another goal for the future is to publish in full colour.

Jennifer Taylor, MPhil

The Estonian Society of Cardiology

Dr T. Marandi, President 2009–2011, discusses the role of this young society in a small Northern European nation

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Toomas Marandi, photo by Raul Mee

The Estonian Society of Cardiology was founded in 1963 and has 226 members—most of them cardiologists, but also from other disciplines closely connected with cardiology—internal medicine and general practitioners.

Our Board is elected for 2 years and is composed of a President, Secretary (next President), Treasurer, and four members. The members are usually elected to equally represent different areas of the country and hospitals where they work.

Cardiologists are mainly located at big hospitals in our Capital, Tallinn, and in our University Hospital in Tartu. In other parts of Estonia, there are fewer cardiologists and several internists are accredited to treat patients with cardiac diseases. With a population of 1.34 million (January 2011), there is one cardiologist per 8934 inhabitants, but more cardiologists per inhabitants in Tallinn and Tartu. To become a cardiologist required 4 years of residency after 6 years of medical training; from 2011/2012 we succeeded to increase the length of our residentship to 5 years.

Our Society has eight working groups (WG):

  • Echocardiography (chair Dr Külliki Karu)

  • Epidemiology and Prevention (chair Prof. Margus Viigimaa)

  • Hypertension (chair Dr Anu Hedman)

  • Interventional Cardiology (chair Prof. Jaan Eha)

  • Paediatric Cardiology (chair Dr Margit Sõnajalg)

  • Arrhythmia (chair Dr Jüri Voitk)

  • Heart Failure (chair Dr Tiina Uuetoa)

  • Acute Coronary Syndromes (chair Dr Toomas Marandi).

Their main responsibilities are to cover certain subspecialities, review guidelines, and prepare scientific meetings. Moreover, much attention has been paid to certification of different subspecialties' and centres' lately.

In 2005, the Society recommended 17 hospitals for the treatment of patients with ST-elevation myocardial infarction (MI). Now 7 hospitals [including 2 with 24/7 percutaneous coronary intervention (PCI) service] has been recommended for the whole country (Figure 1).

Figure 1

Location of recommended hospitals for treatment of ST-elevation myocardial infarction in Estonia. Blue arrows indicate 24/7 percutaneous coronary intervention hospitals, and red arrows indicate hospitals where thrombolysis is primary reperfusion and later patients are transferred to 24/7 percutaneous coronary intervention hospitals.

Hospitals applying to be included in the recommended list are evaluated on the basis of workload [number of acute MI (AMI) patients hospitalized and reperfusion procedures performed] and internal quality control indicators. In 2011, we initiated that 24/7 PCI hospitals should have an intensive coronary care unit (ICCU) to treat these patients appropriately. For example, in 2010, the ICCU in North Estonia Medical Centre (located in Tallinn) treated 2232 patients including 1068 with AMI using 12 ICU beds.

Our interventional cardiology WG initiated certification procedures for interventional cardiologists where a minimum workload is needed to work as a primary PCI operator or to perform elective planned procedures.

In 2010, the four Estonian hospitals with cath labs performed 4590 coronary angiograms and 2041 PCIs per million population.

I am happy to say that after several years of hard work, we changed our AMI registry from a local database to a state registry. We plan that each year a number of hospitals will join our state registry, allowing us to compare our data with other countries worldwide.

During earlier years, we tried preparing our own treatment guidelines but discontinued due to a lack of resources. Instead, we endorse the European Guidelines and translate selected pocket versions and add recommendations that apply locally. This is also helpful during negotiations with our Health Sick Fund to find ways of providing reimbursement. Good examples are publications of pocket guidelines on Myocardial Revascularisation and Pulmonary Hypertension.

Four scientific meetings are arranged annually for important topics and new guidelines, some of them in collaboration with other Physician Societies (cardiac surgeons, pulmonologists, anaesthesiologists, etc.). We obtain valuable expertise from joint sessions with the European Society of Cardiology, where highly recognized opinion leaders have participated with brilliant lectures at our meetings.

Our Board has implemented strong financial discipline during the last years as has Estonia nationally, which successfully assisted our joining the Euro countries. Our budget and main activities for the following year are approved by members at the annual meeting each December, where our aims and utilization of resources are also discussed.

Toomas Marandi, FESC

The London Marathon debate

Endurance exercise, can you have too much of a good thing?

As part of the 2011 London Marathon medical conference, Prof. Sanjay Sharma (Medical Director of the London Marathon) and Dr Andre La Gerche (post-doctoral sports cardiology researcher) debated whether high volume and intensity endurance training continued to exact the same health benefits as more moderate exercise regimes.

There is a wealth of observational data demonstrating that exercise is a powerful intervention in both the prevention and treatment of many of the most pressing global health concerns—obesity, diabetes, atherosclerotic heart disease, and some cancers. Blair et al.1 reported a reduction in cardiovascular and all-cause mortality in a large cohort of healthy middle-aged subjects but simultaneously suggested an ‘asymptote of benefit’ beyond which further improvements in health outcomes were no longer significant. This asymptote was estimated to be around 9 METS for women or 10 METS for men, an intensity that is approximately half that at which competitive endurance athletes regularly train. Relatively little attention has been paid to the study of health outcomes in those engaged in regular training and competition at intensities beyond this relatively modest ‘asymptote’.

There has been a 20-fold increase in marathon participation (www.runningusa.org) over the past three decades. Once considered an extreme event in which only the most avid runners competed, more than a million runners over a wide range of ages and ability now compete in one of more than 500 international marathons held each year. There has been a similar exponential growth in other endurance sports with, for example, 1.2 million triathlon competitors in the USA last year—a 50% increase in the last 3 years. Thus, we have a paradox in which there is an expansion in the number of obese and sedentary individuals paralleling a similar increase in those taking part in unprecedented hours of intense exercise. Whilst there is a concerted well-evidenced push to reduce inactivity, there is little guidance available as to the other end of the exercise debate—can you have too much?

There are some important studies which should provide some reassurance to athletes. Kujala et al.2 documented superior all-cause mortality amongst Finish Olympic athletes from the amateur era (1920–1965) when compared with average population statistics. These improved health outcomes may be attributable to regular exercise, but may also be due to differences between athletes and the general population in other lifestyle factors (e.g. smoking, diet, obesity, socioeconomic status, etc.) or prerequisite health status (the so-called ‘healthy cohort’ bias). In fact, the greatest disease-specific mortality reductions were observed in smoking-related conditions such as lung cancer and chronic lung disease, thus highlighting the difficulties in isolating exercise as a measurable intervention. There are very few studies which compare competitive athletes with adults adhering to current lifestyle recommendations, i.e. high-dose exercise vs. current best practice. van Saase et al.3 reported the long-term outcomes of competitors in the 11 cities ice-skating tour (‘De Elfstedentocht’), a race which brings the Netherlands to a standstill. When compared with the general Dutch population, there was reduced mortality amongst amateur ‘recreational tour’ participants but not amongst the competitive athletes after 32 years follow-up.  Thus, more may not be better than enough.  However, there remains far too little evidence on which to base such an assertion.

The absence of good epidemiological data creates a fertile environment for strenuous debate based on circumstantial evidence and extrapolation. In recent times, much attention has been given to the findings of post-exercise cardiac biomarker release and transient myocardial dysfunction or ‘fatigue’. Whether these findings represent damage or part of the normal physiological process of stress, repair, and recovery are yet to be elucidated. There have also been a number of cohort studies demonstrating an increase in atrial arrhythmias amongst endurance athletes, particularly when follow-up includes former athletes now in their middle-age and older. In light of these studies, one may argue that long-term endurance exercise may, at least in some athletes, create a substrate for arrhythmias. The well-established phenotype of the ‘athlete's heart’ is assumed to be a purely physiological response to training where myocytes increase in size and number with limited or no expansion of the extracellular matrix, but this is difficult to prove. Recent doubt has been shed on this premise by the findings of myocardial inflammation, fibrosis, and a reduced arrhythmia threshold amongst endurance trained rats,4 whilst in humans, newer tissue characterization techniques such as delayed enhancement on magnetic resonance imaging have been used to detail patches of fibrosis amongst the hearts of highly trained veteran athletes.5 However, once again, the long-term implications of such findings remain unaddressed.

The vast increase in the popularity of endurance competition coincides with an increasing number of questions being raised about the safety of such pursuits. After a long debate on whether you can have ‘too much of a good thing’, the combatants came to a unanimous conclusion—we don't know. However, as an increasing proportion of the population are investing in the answer, it is time we started finding out.

Dr André La Gerche, Cardiologist, University Hospital Leuven, Belgium

Prof. Sanjay Sharma, Medical Director of the London City Marathon

CardioPulse contact: Andros Tofield, MD, FRCS, FACEP, Managing Editor CardioPulse, EHJ. Email: docandros{at}bluewin.ch

References