OUP user menu

CardioPulse ArticlesESC Congress 2013 Late Breaking TrialsESC Congress 2013 Clinical Trial UpdatesESC Congress 2013 Basic and Translational Science Hot LinesHeart failure treatment to rival statins for hypercholesterolaemia?Announcement17th International Congress on Advances in Cardiac UltrasoundThe future of cardiologyCorrigendum

DOI: http://dx.doi.org/10.1093/eurheartj/eht425 3237-3244 First published online: 7 November 2013

ESC Congress 2013 Late Breaking Trials

Hot Line I: Late Breaking Trials on Thrombosis

The Hokusai VTE study (Harry Büller, Netherlands) revealed that once daily edoxaban after heparin was noninferior and caused significantly less bleeding compared to high quality standard therapy in a broad spectrum of venous thromboembolism (VTE) patients. Edoxaban was noninferior to warfarin for primary efficacy (symptomatic VTE) with 130 (3.2%) versus 146 (3.5%) events respectively (HR = 0.89; p < 0.001 for noninferiority).

TASTE (Ole Fröbert, Sweden) left little role for manual thrombus aspiration as a routine adjunct to PCI in STEMI. This large, prospective, registry-based randomized clinical trial showed no reduction of mortality at 30 days, no significant reduction of hospitalization for MI or of stent thrombosis at 30 days, and no reduction of other important clinical endpoints during hospitalization.

The Treatment of Acute Coronary Syndromes with Otamixaban (TAO) trial (Philippe Gabriel Steg, France) did not support the use of otamixaban for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing planned early percutaneous coronary intervention. Otamixaban did not reduce the rate of ischemic events relative to unfractionated heparin plus eptifibatide but did increase bleeding.

RE-ALIGN (Frans Van de Werf, Belgium) was the first randomized study comparing a novel oral anticoagulant with warfarin in patients with a mechanical heart valve. It found that dabigatran was not as effective as warfarin for prevention of thromboembolic complications and was associated with more bleeding. The study concluded that dabigatran should not be prescribed in patients with mechanical heart valves.

The 2 year follow up of the PARIS Registry (Roxana Mehran, US) showed that the risk of MACE events after dual antiplatelet therapy (DAPT) cessation post PCI was not uniform but varied by mode, circumstance for cessation, and attenuated over time. While most events following PCI occurred among patients on DAPT, the relative risk due to brief interruptions or disruption remained substantial.

Hot Line II: Late Breaking Trials on Intervention and devices

PRAMI (David Wald, UK) demonstrated that in acute STEMI with multivessel coronary artery disease, immediate preventive angioplasty to significantly stenosed non-culprit arteries substantially improved outcome compared with angioplasty to the culprit artery alone, with primary outcome (cardiac death, nonfatal myocardial infarction or refractory angina) rates of 9 per 100 and 23 per 100 respectively (HR = 0.35, p < 0.001) after 23 months.

ACCOAST (Gilles Montalescot, France) revealed that in NSTE-ACS patients managed invasively within 48 hours of admission, pre-treatment with prasugrel did not reduce major ischemic events through 30 days but increased major bleeding complications. The results were consistent among patients undergoing PCI supporting treatment with prasugrel once the coronary anatomy had been defined.

DECAAF (Nassir Marrouche, US) showed that delayed enhancement (DE)-MRI quantification of atrial fibrosis in atrial fibrillation (AF) patients is feasible and reproducible. Initial and residual fibrosis were strong and independent predictors of procedural outcome in patients undergoing ablation of AF.

PRAGUE 14 (Petr Widimsky, Czech Republic) found that delayed (or no) interruption of antithrombotic therapy with aspirin or warfarin before major non-cardiac surgery in cardiac patients did not prevent perioperative ischemic or thrombotic complications, and increased the risk of bleeding complications. The traditional strategy of one week interruption of antithrombotic drugs should not be changed.

LINC (Sten Rubertsson, Sweden) found no difference in short or long-term survival up to 6 months between out-of-hospital cardiac arrest patients treated with mechanical CPR using the LUCAS device compared to manual CPR. There was good neurological outcome in the vast majority of survivors in both groups.

IN-TIME (Gerhard Hindricks, Germany) evaluated the effects of cardiac implant based home monitoring on clinical outcome in advanced heart failure. At 12 months follow-up total mortality was significantly lower in the home monitoring arm compared to regular follow up (3.0% versus 8.3%; p< 0.01).

Hot Line III: Late Breaking Trials on Risk factors and Diabetes

PURE (Salim Yusuf, Canada) found that risk factor burden was highest and CVD mortality lowest in high (HIC) versus middle (MIC) and low (LIC) income countries. The data suggest that the high CVD risk factor burden in HIC is mitigated by better risk factor control, more aggressive management of less severe CVD, and better outcomes in those experiencing major CVD leading to much lower CVD mortality.

EXAMINE (William B. White, US) was a long-term cardiovascular outcomes safety trial of the DPP-4 inhibitor alogliptin in patients with diabetes and acute coronary syndrome (ACS). The trial met its primary endpoint. Alogliptin showed no increase in major adverse cardiovascular events in patients with type 2 diabetes and recent ACS after a median treatment period of 18 months.

SAVOR-TIMI 53 (Deepak Bhatt, US) found that the diabetes drug saxagliptin did not increase the risk of cardiovascular death, MI, or ischemic stroke in diabetic patients with CVD or multiple risk factors. However, the drug did not reduce macrovascular events either. An unexpected finding was a slight, but statistically significant, increase in hospitalizations for heart failure with saxagliptin versus placebo.

ASSURE (Stephen Nicholls, Australia) aimed to determine the effects of apolipoprotein A1 (apoA1) induction with RVX-208 on coronary atherosclerosis progression. In patients with coronary artery disease, administration of RVX-208 showed no greater increase from baseline in apoA1 or HDL cholesterol than placebo-treated patients. No incremental beneficial effects of RVX-208 on any parameter of plaque progression were observed.

COMPARE (Maarten Groenink, Netherlands) evaluated the effect of losartan on aortic dilatation rate in adults with Marfan syndrome (MFS). Patients with MFS have an increased risk of life-threatening aortic complications, mostly preceded by aortic dilatation. A total of 233 patients (47% female) underwent randomization to losartan (n = 116) or no additional treatment (n = 117). Follow-up was 3.1 ± 0.4 years. Results were published in EHJ .

Eur Heart J (2013) doi: 10.1093/eurheartj/eht334 http://eurheartj.oxfordjournals.org/content/early/2013/08/21/eurheartj.eht334.full.pdf+html

Hot Line IV: Late Breaking Trials on Heart Failure and Acute Coronary Syndrome

Xavier Jouven (France) presented data on the mortality of French participants from the Tour de France during 1947-2012. Compared to the general population, overall standard mortality ratio (SMR) was 0.59 (p < 0.0001) and mean additional life expectancy was 6.3 ± 2 years. The cyclists had a significant reduction in cardiovascular and cancer deaths, but mortality related to accidents was similar.

ATOMIC-AHF (John R. Teerlink, US) assessed the effect of intravenous omecamtiv mecarbil (OM) in patients with acute heart failure (AHF). There was no significant difference between OM and placebo on the primary efficacy endpoint of dyspnoea relief (assessed by a 7-point Likert scale), but there were favourable dose- and concentration-related trends in dyspnoea response.

EchoCRT (Johannes Holzmeister, Switzerland) evaluated the effects of cardiac resynchronization therapy (CRT) on morbidity and mortality in patients with symptomatic heart failure on stable, optimal medical therapy with impaired LV systolic function, QRS complex <130ms and ventricular dyssynchrony. The study found that CRT did not improve clinical outcomes in symptomatic heart failure patients with low ejection fraction and QRS < 130ms.

AQUARIUS (Stephen Nicholls, Australia) examined the effects of renin inhibition with aliskiren on progression of coronary atherosclerosis. In patients with prehypertension and coronary artery disease, the use of aliskiren compared with placebo did not result in improvement or slowing of progression of coronary atherosclerosis. The findings did not support the use of aliskiren for regression or prevention of progression of coronary atherosclerosis.

The Biomarkers in Cardiology-8 Study (BIC-8) (Martin Möckel, Germany) revealed that a biomarker strategy using a state-of-the-art quantitative troponin assay in combination with ultrasensitive copeptin can aid safe and early discharge in low to intermediate risk patients presenting with suspected ACS. Some 66% of patients in the copeptin group were discharged from the Emergency Department versus 12% in the standard group (no copeptin).

Jennifer Taylor, MPhil

ESC Congress 2013 Clinical Trial Updates

Clinical Trial Update Hot Line I: Updates on hypertension, heart failure and diabetes

Women comprise less than 30% of patients in randomized trials investigating DES in CAD patients, revealed research by Roxana Mehran (US). Use of DES in women was safe and effective compared to BMS during long-term follow-up. Among women, newer-generation DES were associated with improved safety outcomes compared to early-generation DES.

RAFT (L. Brent Mitchell, Canada) showed that use of beta-blocker (BB) therapy remains paramount in congestive heart failure (CHF) patients, with benefits independent of those of newer CHF treatments. Benefits were dose-dependent, emphasizing the need to optimize BB dose in advanced CHF patients with or without cardiac resynchronization therapy.

RELAX-AHF (Marco Metra, Italy) showed the effects of serelaxin versus placebo were homogenous across multiple subgroups on the primary dyspnoea relief endpoints, 60-day composite outcomes and 180-day mortality. Larger benefits were in elderly patients, patients without previous heart failure hospitalization, atrial fibrillation, not previously treated with renin-angiotensin-aldosterone system antagonists, and with inflammation.

ASTRONAUT (Aldo Maggioni, Italy) showed that the addition of aliskiren to standard therapy had no effect on post-discharge outcomes of patients hospitalized for heart failure. Pre-specified subgroup analysis by baseline diabetes mellitus status revealed a significant interaction for 12 month all-cause mortality and suggested improved survival at 12 months in non-diabetics taking aliskiren.

SHIFT (Adriaan Voors, Netherlands) showed that in chronic stable systolic heart failure patients, heart rate is directly and independently associated with risk of worsening renal function. Reduction in heart rate by ivabradine had a neutral effect on renal function during 2 years of follow-up.

ORIGIN (Linda Mellbin, Sweden) revealed that severe, but not non-severe, hypoglycemia increases risk for CV outcomes in people at high CV risk and dysglycemia. Risk did not relate to insulin glargine-mediated normoglycemia, but was apparent in the presence of standard glucose lowering therapy. Nocturnal hypoglycemia did not predict arrhythmic or CV death.

Clinical Trial Update Hot Line II: Updates on intervention and devices

Symplicity HTN-1 (Henry Krum, Australia) showed that blood pressure reductions following renal denervation (RDN) in treatment-resistant hypertension patients persist through 2 and 3 years follow-up. A proportion of patients appeared to be late responders to RDN treatment which was not explained by medication changes.

MADIT-CRT LIFR (Ilan Goldenberg, Israel) revealed that at 6 years' follow-up the cumulative probability of heart failure (HF) or death was 32% in patients who had cardiac resynchronization therapy with a defibrillator (CRT-D) versus 45% in ICD-only patients (p < 0.001). CRT-D was associated with a 40% reduction in the long-term risk of HF or death compared to ICD-only (p = 0.001).

A pre-specified patient level data meta-analysis of three CHAMPION trials (PCI, PLATFORM, PHOENIX) presented by Christian Hamm (Germany) showed that compared with clopidogrel, cangrelor may be useful as an adjunct to aspirin and anticoagulation for patients undergoing PCI to decrease periprocedural thrombotic complications, albeit at the expense of increased non-fatal bleeding.

The 12-month follow-up from IABP-SHOCK II (Holger Thiele, Germany) showed that IABP did not significantly reduce mortality in patients with cardiogenic shock complicating acute MI with an early revascularization strategy. Quality of life was good in cardiogenic shock survivors.

A post-hoc stratified analysis of PARTNER (Brian Lindman, US) suggested that in patients with diabetes and severe aortic stenosis who are at high-risk for surgery, there is a survival benefit, no increase in stroke, and less renal failure from treatment with TAVI replacement compared to surgical aortic valve replacement.

The 2 year follow up of EVOLUTION (Lei Ge, China) suggested that sirolimus eluting stents (SES) with biodegradable polymers are comparable to SES with durable polymers for clinical efficacy and safety in patients with de novo coronary artery lesions. There was no difference in the incidence of late stent thrombosis and very late stent thrombosis.

Clinical Trial Update Hot Line III: Updates on risk and outcome

PURE-Sodium (Andrew Mente, Canada) showed that dietary sodium reduction and potassium increase likely reduce blood pressure to a greater extent in those with high sodium consumption, hypertension and the elderly, and have substantially lesser effects in those with moderate or low levels of sodium consumption, younger individuals and non-hypertensives.

ARCTIC-GENE (Jean-Philippe Collet, France) found that the predicted genetic clopidogrel metabolic phenotype was a good marker of clopidogrel response but was unrelated to clinical outcome. The primary outcome (composite of death, MI, stent thrombosis, stroke or urgent revascularization 1 year after stent implantation) occurred in 32.2% of rapid and 32.7% of slow metabolizers (HR 0.988, p = 0.90).

The Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia (TASTE) trial (Stefan James, Sweden) incorporated a randomization module in the clinical nationwide SCAAR/SWEDEHEART registry. TASTE showed that prospective Registry based Randomized Clinical Trials (RRCTs) are an effective, inexpensive way to appropriately assess hard clinical endpoints in large patient cohorts.

Data from the vitamin K antagonist (VKA) arm of the AMADEUS trial was used to develop and validate novel composite scores for stroke/thromboembolism/bleeding in patients with atrial fibrillation. Gregory YH Lip (UK) presented the predictive or practical clinical utility of these new scores compared to existing individual stroke and bleeding risk scores.

REGARDS (Maciej Banach, Poland) suggested that for all patients over 55 years the recommended level of systolic blood pressure (SBP) should be <140 mmHg, including the oldest patients (>75 years old), with the most reasonable values between 120-139 mmHg. Intensive hypertension therapy (with targeted BP < 120 mmHg) should be investigated further.

High-STEACS (Nicholas Mills, UK) showed that compared to men, women with suspected acute coronary syndrome are more likely to be misdiagnosed and under-treated for myocardial infarction. A high-sensitivity troponin assay doubled the diagnosis of myocardial infarction in women (from 13% to 23%; p < 0.001) but had a minimal effect in men.

Jennifer Taylor, MPhil

ESC Congress 2013 Basic and Translational Science Hot Lines

Basic and Translational Science Hot Line I: Vascular Research

Endothelial microparticles (EMP) promote vascular endothelial repair by delivering functional microRNA-126 into recipient cells, according to Felix Jansen (Germany). This leads to downregulation of target protein Spred1 and improves migratory and proliferative endothelial cell (EC) capacity with subsequent improvement of EC repair. In pathological hyperglycaemic conditions, EMP-mediated miR-126 induced EC repair is altered.

Jiang-Ning Yang (Sweden) showed a novel role for arginase 1 in control of endothelial nitric oxide synthase (eNOS) function in red blood cells (RBCs). Inhibition of arginase unravelled an important functional effect of RBC-derived NO that mediated protection against myocardial ischemia/reperfusion injury.

Neus Bellera Gotarda (Spain) presented a potentially promising therapeutic approach that could be translated to patients who suffer a large MI. Early intracoronary administration of antagomir-92a encapsulated in microspheres (Antag92aME) in a pig model of reperfused MI prevented ventricular remodelling with no local or distant adverse effects.

Paul Teunissen (Netherlands) hypothesized that arteriogenesis could be stimulated using monoclonal antibodies inhibiting interferon-beta signalling without accelerating atherosclerosis. He demonstrated that blocking interferon-alpha/beta receptor subunit 1 (IFNAR-1) using monoclonal antibodies stimulated collateral artery growth in a murine hindlimb-ischemia model and had a neutral effect on atherosclerosis.

Sander W. van der Laan (Netherlands) presented the first report on the association of common genetic variants to histological plaque phenotypes. The study included 831 patients from the Athero-Express Biobank Study who underwent carotid endarterectomy and were genotyped. Common variants near PIK3CG were associated with atherosclerotic plaque haemorrhage and vessel density.

Vascular endothelial growth factor (VEGF) is a potent angiogenic and anti-apoptotic factor, which may facilitate the engraftment of transplanted cells and guide angiogenesis. Rosalinda Madonna (Italy) demonstrated that VEGF-loaded pharmacologically active microspheres (PAM) coated with adipose tissue-derived mesenchymal stromal cells (AT-MSCs) may have therapeutic applications for enhancing angiogenesis and AT-MSC survival in the harmful microenvironment of post-ischemic tissues.

Basic and Translational Science Hot Line II: Cardiac Research

Antje Voigt (Germany) investigated the ubiquitin-like modifier interferon-stimulated gene 15 kDa (ISG15) in the pathogenesis of dilated cardiomyopathy (DCM). ISGylation promoted viral clearance, attenuated inflammatory injury, limited cardiac remodelling and prevented DCM in Coxsackievirus B3 (CVB3)-cardiomyopathy. Pharmacologic inhibition of USP18-isopeptidase activity might be a promising novel therapeutic approach in viral cardiomyopathy.

Guido Tarone (Italy) presented melusin gene therapy as a novel approach to fighting familial dilated cardiomyopathy. Melusin is a muscle specific chaperone protein required for cardiac compensatory response to stress conditions. Overexpression of melusin effectively counteracted dilated cardiomyopathy in a mouse model, mimicking human Emery Dreyfus familial cardiomyopathy caused by LaminA H222P mutation.

Morten Olesen (Denmark) tested the hypothesis that mutations in the KCNK3 gene that encodes the two-pore domain potassium channel, K2P3.1 (TASK-1) might predispose to atrial fibrillation. Cardiac action potential modelling suggested that loss-of-function of TASK-1 was associated with a prolongation of atrial action potential duration and can promote atrial fibrillation.

Rosalinda Madonna (Chieti, IT) demonstrated that adipose tissue-derived stromal cells (ADSCs) improve ischemic muscle metabolism and increase neovasculogenesis in diabetic rats with hind limb ischemia. She concluded that 1H-MRS (a combination of magnetic resonance imaging and spectroscopy) is a useful tool to monitor attempts at salvaging the ischemic tissues with cell-derived novel therapies.

Maria Borrell (Spain) showed that the modulation of the LDL receptor-related protein 5 (LRP5) and the canonical Wnt pathway in hypoxic cardiomyocytes and in porcine and human ischemic myocardium is a defensive pro-survival process of the damaged myocardium triggered to restore cell viability. It suggests that therapeutic interventions targeting LRP5 may favour cardiac healing after MI.

Noemi Pavo (Austria) showed that overexpression of the myogenic factor MEF2c and repression of caspase was related to decreased infarct size and improved cardiac function in a porcine model of chronic myocardial infarction treated with secretome of apoptotic peripheral white blood cells (APOSEC).

Embedded Image

Heart failure treatment to rival statins for hypercholesterolaemia?

The academic appointed to plan a medical school at Luxembourg University, Prof. Ludwig Neyses, MD, has discovered inhibitors of genes implicated in heart failure and dreams of developing drugs that slow its development, and may even be effective prophylactically, reports Barry Shurlock PhD

Every so often a group of very senior academics gather for a few days at various institutions in the UK. Here, they receive talks from some of the leading business thinkers in the world. They are undertaking a module in a leadership course at the Saïd Business School of the University of Oxford. They are (the deans, vice chancellors, vice-presidents, and presidents of the present and the future) wedded to the idea that higher education must be entrepreneurial—not only in the sense of turning research findings into cash, but also using institutions as hubs to infuse new ideas and an entrepreneurial spirit into the surrounding population.

Embedded Image

One of the attendees is cardiologist Prof. Ludwig Neyses, who, in April 2013, became vice-president for Research at the University of Luxembourg. His move follows 12 years in the UK as professor of medicine and cardiology at the University of Manchester. Talking of this stage of his career, he said: ‘I was spreading my wings! I had published several substantial papers on molecular cardiology and heart failure and was ready to move on. I applied for a chair at Trinity College Dublin, but it went to a local candidate. A week later I had a letter from the external adviser for the post, who quickly came up with a job offer and an endowment that was unbeatable. The research thrived, there was a lot of money, including 3 or 4 Medical Research Council grants and EU money. Amongst other things, I set up one of the largest heart failure clinics in the UK’.

Outlining his research at Manchester, he said: ‘The major contribution was probably the discovery that calcium-based signalling mechanisms in the myocardium are mediated through the sarcolemma calcium pump, unravelling a completely new role for this pump, which is an ideal pharmacological target to treat heart failure. More recently we have focused on the role of tumour suppressor genes in heart failure and cardiac hypertrophy – the concept that the same genes might be associated with heart failure as with cancer is a fascinating new concept. We have experimental evidence that such a mechanism is causal in animal models, in which the deletion of tumour suppressor genes causes the heart to grow to an immense size’.

Embedded Image

Grund in Luxembourg City, a UNESCO World Heritage Centre

Despite his move to Luxembourg, Prof. Neyses will continue working with the group in Manchester, where agents that inhibit the sarcolemma calcium pump are being studied. These could form the basis of novel pharmaceutical treatment for chronic heart failure, and even possibly for prophylactic treatment, along the lines of statins for hypercholesterolaemia. Another major clinical finding of the group is that insulin resistance is much more frequent in heart failure than formerly suspected and intermittent atrial fibrillation, and associated stroke risks, are accentuated in such patients.

Prof. Neyses is a Rhinelander by birth, but speaks fluent English and French, and is currently learning Spanish. Describing his undergraduate days, he said: ‘At first I was studying physics and chemistry with medicine in Mainz, but Professor Grote persuaded me to concentrate on medicine. I spent a year in Montpellier, in France, and did my final year at the Westminster Medical School in London. It was a lovely place – I went there with a friend and have very fond memories of the time. Likewise Montpellier, where I learnt a lot of French and medicine, and subsequently married a girl from the city!’

After qualifying, he went to work with hypertension specialist Dr Willi Vetter at the University Hospital, Zurich, and then worked on calcium transport in the myocardium with Prof. Ernesto Carafoli, at the Swiss Federal Institute of Technology in the city. He subsequently trained in internal medicine at Bonn. A key part of his career at this time was the 9 months he spent in North Carolina with Dr R. Sandy Williams at Duke University, learning the techniques of molecular biology. He said: ‘It was the birth of molecular cardiology. I was amongst the first, if not the first, in Europe to apply molecular biology to biological questions of cardiology. The biochemistry and science of Vetter and Carafoli, together with the methodology and drive and spirit of the US lab, really sparked my research career’.

His time at Duke and Bonn gave him ‘a toolbox’ in molecular cardiology that led to an associate professorship at the University of Würzburg, where he worked with Drs Kurt Kochsiek and Georg Ertl. He said: ‘It was here that I really started producing major publications as a physician-scientist. It was a marvellous job in a wonderful cardiovascular group. It was also clinically very fulfilling’.

As a vice-president of Luxembourg University he now will be able to put all his experience into a European institution that seems set to grow. He says his main job is to ‘refine the strategic priorities’ of all research carried out there, with the aid of a €5 million annual ‘internal grant’. Explaining why he got the job, he said: ‘Apart from my language skills, I was hired was to do a feasibility study for a new medical school over 2–3 years, though priorities changed and I actually had to do it in the first 6 weeks! I had no previous links with Luxembourg other than being a Rhinelander and neighbour. The conditions are wonderful, not only for grants and equipment, but also staffing and salaries. Also we are at the very centre of Europe. I find it truly rewarding to take up the challenge of a complete career change at this relatively late stage of my career’.

17th International Congress on Advances in Cardiac Ultrasound

This outstanding biennial course takes place again in 2014, with the latest state-of-the-art developments

Embedded Image

This is one of the oldest courses on advanced cardiac ultrasound in Europe established some 32 years ago by Prof. Jos Roelandt from Rotterdam.

Embedded Image

(Photo credit Sam Rogers)

Prof. Jeroen J. Bax from Leiden, NL (photo left) and Prof. Petros Nihoyannopoulos from London, UK (photo right), took over the organization of this prestigious course in 2008 and built on its previous success. This course runs every 2 years and concentrates on the most recent advances in cardiac ultrasound and their relevance for clinical problem solving in everyday clinical practice. State-of-the-art lectures will provide cardiologists and those interested in cardiac ultrasound a review of all current clinical challenges and new developments and how to implement them in daily practice. Particular emphasis will be on quantitative Doppler haemodynamics, state-of-the-art 3D and 4D echocardiography, the role of echo in arrhythmias, diastology, how to assess valve regurgitation in the twenty-first century, as well as echo in emergencies and other important clinical scenarios.

Lectures will be delivered by high-quality international masters of echocardiography including Jo Kisslo (USA), Itzhak Kronzon (USA), Fausto Pinto (Portugal), Patrizio Lancellotti (Belgium), Francesco Faletra (Switzerland), Joachim Nesser (Austria), Raphael Rosenhek (Austria), Mark Monaghan, Roxy Senior, and Mike Bellamy from the UK.

Embedded Image

The course is known for the extensive discussions and interactions between participants and faculty and is supported by the European Association of Cardiovascular Imaging.

The course will be in one of the most spectacular locations in Europe, the city of Davos, Switzerland, at 1560 m above sea level the highest city in Europe. It is renowned for hosting the annual World Economic Forum as well as many other medical meetings with its impressive Conference Centre. Davos is easily accessible by car, and train from Zurich.

For further information on the course: www.regonline.co.uk/davos2014; programme: https://www.regonline.co.uk/custImages/250000/259886/Davos/2014/Davos-finalprogramme-2014.pdf

Tel: +44 (0)2033131606. Email: info{at}w12conferences.co.uk

The future of cardiology

Dr Stéphane Zuily discusses future cardiology training on behalf of the Cardiologists of Tomorrow (CoT) nucleus

Embedded Image

CoT nucleus: Ricardo Fontes-Carvalho, Ewa Jonkowska, Michal Pazdernik, Janine Pöss, Ildiko Racz, Rafael Vidal-Perez, Stéphane Zuily

Cardiology is changing fast. Over the past decade, there has been an explosion of cardiovascular science and technology. Cardiologists in training will have to face many challenges. One of them will be to go through personalized medicine designed for coupling established clinical as well as pathological indexes to create diagnostic, therapeutic, and prognostic strategies tailored to each patient's requirements.1 This shift towards a deeper understanding of disease will lead to a transition from the World Health Organisation's International Classification of Disease to a ‘New Taxonomy of Disease’, a revised classification based on intrinsic biology as well as traditional clinical signs and symptoms.2 Moreover, trainees will have to face other issues such as high-quality medicine without lower performance and sub-specialization in the pursuit of clinical excellence. However, in the next decade, preventive measures will expand more quickly than interventions.3 Humanity towards patients will still be mandatory: trainees will have to know their patients as individuals.

Embedded Image

As Sir William Osler said, ‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’.4 Finally, the rules and regulations for Fellowship training will be more stringent than ever and limited funding opportunities will remain a matter of concern. To keep up with our expanding speciality, the cardiology community will have to understand new educational needs and propose insights to teach, educate, and mentor trainees to become competent cardiovascular specialists.

Challenging issues

The ESC will have to deal with several issues.

Knowledge and training

ESC has recently launched an innovative platform called ESCeL (ESC eLearning platform) that is totally devoted to the trainees of the different cardiology sub-specialties in Europe. It is a very important tool which will allow trainees across Europe and other countries outside Europe as well to go through their training programme and to acquire not only the knowledge, but also the practical and professional skills that they will need in the future as sub-specialists. National Cardiac Societies will have a crucial role in this project to supervise the training programme and, also, in the verification of the data quality uploaded by the trainees. Basically, the aim of the ESCeL platform will be to harmonize the training of the sub-specialties across Europe in order to allow, as per the EU Directive, the free movement of doctors and patients. There is a need to set up standards not only for the care of the patients but also for training. The ESCeL platform will allow this, not only across sub-specialties, but also across borders.

In this digital world, the primary objective of the ESC is to embrace changes, improve the way cardiologists communicate and enhance their ability to obtain continuing education at the point of care. For instance, during the past ESC Congresses, special sessions were webcasted live, allowing cardiologists all over the world to attend these sessions from their hospital or from home. Similarly, online seminars (webinars) proposed by the ESC are being progressively incorporated into medical training. As ‘massive open online courses’, they could be the future of medical education.5

Changes in medical practice characterized by the expanding options for diagnosis and management and advances in technology are contributing to a greater use of simulation technology in medical education. A recent meta-analysis demonstrated that, compared with no intervention, technology-enhanced simulation training in the education of health professionals is consistently associated with large beneficial effects for outcomes of knowledge, skills, and behaviours, and moderate effects for patient-related outcomes.6 Thus, it seems clear that simulation-based learning in cardiovascular medicine will become an integral part of the training of cardiologists, ensuring their ongoing competence with the objective of delivering improved patient outcomes.7


Mentorship comes from Greek mythology; Mentor was a loyal advisor of Odysseus, and teacher of his son, Telemachus. Throughout history, a mentor has come to be equated with a prudent advisor who serves as a teacher or coach. At times, the mentor–mentee relationship is viewed as vertical or hierarchical and self-limited in time. Successful mentorship is vital to career success and satisfaction for both mentors and mentees. Based on a recent qualitative study defining the ideal qualities of mentorship, outstanding mentors: (i) exhibit admirable personal qualities, including enthusiasm, compassion, and selflessness, (ii) act as a career guide, offering a vision, but purposefully tailoring support to each mentee, (iii) make strong time commitments with regular, frequent, and high-quality meetings, (iv) support personal/professional balance, and (v) leave a legacy of how to be a good mentor through role modelling and instituting policies that set global expectations and standards for mentorship.8 In summary, mentorship is a vibrant and fulfilling experience that affords limitless opportunities, not only for the mentee but also for the mentor. Successful mentoring requires commitment and interpersonal skills of the mentor and mentee, but also a facilitating environment at academic medical institutions.9,10 Therefore, we hope that the ESC will continue to promote and strengthen intergenerational relationships between mentors and mentees.

Embedded Image

Dr Edward D. Miller, past Dean of John Hopkins University School of Medicine, once said ‘Today's medical students are the seed corn for tomorrow's medicine. For the sake of the future of healing, we must help them flourish’.


Research fellowship can give an excellent opportunity to gain more experience in research for building up a long-term and fruitful collaboration between two institutions. The ESC has already developed a wide range of grants to help cardiologists in training to access quality training or research activities throughout Europe. ESC Training and Research grants also include offers for specific topics of Cardiology proposed by ESC Associations, Working Groups, or Councils.

A driving force for change is coming from all national and affiliated cardiac societies of the ESC. One of the major ESC initiatives is to provide best career resources and maximize growth of all young professionals across Europe and, thus, international exchange programmes are a crucial area of ESC interest. The main objective is to assemble the best cardiology centres of ESC member countries who are willing to participate in international exchange programmes dedicated to young cardiologists to enable them to gain experience in their training. Cardiology fortunately attracts some of the brightest medical graduates who, at least in the early stages of their career, are keen to undertake research. It is in best interests of National Cardiac Societies/ESC to ensure that such individuals are given every opportunity to fulfil their academic potential within the specialty. Through cooperation between members and affiliated countries, there is an opportunity to establish European cardiology Fellowships and training at the forefront of international cardiovascular medical education.


The future of cardiology is bright. However, some challenging issues must be recognized and addressed to ensure high-quality training/Fellowship programmes for the next generations of cardiologists in training, under the supervision of caring mentors. Thereby, the grand goal of reducing the burden of cardiovascular disease will be pursued under optimal conditions from generation to generation.

Dr Stéphane Zuily Associate Professor, Nancy University Hospital, France. stephane.zuily{at}gmail.com



Corrigendum to: CardioPulse ‘Coronary artery bypass grafting: the past, present, and the future’ [Eur Heart J 2013;34:2855-2856]. In this article it was claimed that Francois Franck proposed sympathectomy for angina pectoris relief in 1989. The correct date was 1899.

View Abstract