Report of 6th Annual EPCCS meeting held in LondonSep. 11, 2013
As part of its aim to provide a focus of support, education, research, and policy on issues relating to cardiovascular disease within primary care settings, the European Primary Care Cardiovascular Society (EPCCS) organised its sixth Annual Scientific Meeting. The Cardiovascular Disease 2013 Clinical Master Class was a 2-day meeting held in London, United Kingdom. A wide range of important cardiovascular topics was covered, including hypertension, diabetes, acute coronary syndromes, arrhythmias, guidelines and lifestyle. Primary care health professionals attended the meeting to be updated on and discuss topics relevant to the management of cardiovascular patients in their daily practices.
Here we give a brief overview of what was discussed at the meeting, and provide you with links to the slides, presentations and brief webcasts in which the presenters summarise their talks.
Prof.dr. Richard Hobbs (Oxford, UK) opened the scientific session with a rapid clinical update on developments in the field since the last EPCCS meeting. He pointed out the good news that most ESC guideline committees now have at least one primary care representative. This is needed because evidence from real primary care practices is crucial in order to make relevant recommendations.
Dr. Neil Munro (Esher, UK) then summarised what is new in diabetes care. He could take away the initial concern that incretin drugs affect pancreatic function, and discussed the pros and cons of other medication such as SGLT2 inhibitors. He also discussed some novel agents, including exercise and calorie restriction mimetics, and novel insulins.
Prof.dr. Richard McManus (Oxford, UK) gave a whistle stop tour of changes in hypertension guidelines. One of the most important developments is probably the heightened focus on out-of-office measurement to exclude white-coat hypertension. Furthermore, because of lack of convincing evidence that a blood pressure lower than 140/90 mmHg is better than 140/90 mmHg, it is no longer recommended to achieve lower values. Also, ESH/ESC guidelines still recommend to treat mild hypertension in low risk patients, while a Cochrane review suggests nil or a marginal effect in this group. Professor McManus calculated that treating this group is an expensive approach for a questionable benefit.
For special subgroups only subtle changes to the guidelines apply. In obese patients: if the cuff does not fit on the upper arm, BP can accurately be measured at the wrist, provided that the wrist is held at the height of the heart.
Prof.dr. Arno Hoes (Utrecht, The Netherlands) discussed the relevance of the many newly developed diagnostic tests using biomarkers to diagnose CVD in primary care; which criteria they should meet. Tests need to be validated in a relevant clinical domain, thus in patients suspected of the disease in the relevant setting, rather than a comparison of patients with or without the disease. A test should have added predictive value on top of the available info, and should be easily applicable.
Prof.dr. Frank Buntinx (Leuven, Belgium) zoomed in on the relevance of new markers in suspected acute coronary syndrome. He discussed the value of using single or multiple biomarker tests in addition to assessment of signs and symptoms. Certain tests seem promising in their ability to rule out acute myocard infarct. These will be studied in a primary care setting in Flanders and The Netherlands. However, GPs who used point-of-care tests in Sweden performed worse than their colleagues who did not, thus diagnostic tests can be a source of false reassurance.
Dr. Geert-Jan Geersing (Utrecht, The Netherlands) gave the only talk on the venous system. Due to the clinical heterogeneity of patients with pulmonary embolism (PE), it is commonly missed. Referral of all patients with suspected PE is, however, not feasible. Combining a clinical decision rule with D-dimer testing has been used in secondary care. This rule-out approach has now also been validated in primary care. D-dimer testing can furthermore identify patients who are at a very high risk of recurrent events, thus who need to continue taking anticoagulants and who might stop.
Dr. Neil Munro climbed on stage once more to speak about diabetes and CV disease. He showed evidence that early control of glycaemia later confers a CV benefit. Although Americans think that Europe does not treat diabetes well enough, dr. Munro concludes that a HbA1c target of 7 is good enough, as opposed to the American target of 6.
He focussed on the pathophysiology of diabetes, and how treatment often causes hypoglycaemia. This is not only unpleasant for the patient, but it also causes unfavourable endocrine, symptomatic and neurological responses, even in non-diabetic subjects. If somebody has hypoglycaemie, they will likely get it again, thus it deserves attention.
Prof.dr. John Camm (London, UK) discussed when it matters to diagnose heart arrhythmias. Many challenges surround a correct diagnosis of atrial fibrillation, as it is often subclinical and it tends to come and go. A multidimensional classification system has been developed in an attempt to personalise the risk.
Prof.dr. Richard McManus addressed the question of whether patients can safely self-manage hypertension. Studies that have looked into this found that patients who are in a combined intervention group of telemonitoring under guidance of nurses had a larger decrease in mmHg than a control group. Although not all patients follow instructions on for instance changing medications, they appear to follow instructions better than doctors.
Prof.dr. Kenneth Dickstein (Bergen, Norway) spoke about cardiac resynchronisation therapy, with a specific focus on the importance of identifying left bundle branch block (LBBB). LBBB in combination with a wide QRS (>120ms) is an indication to consider CRT. To date many eligible patients do not receive it.
The first day ended with a session in which brief presentations were given based on selected abstract submissions. Marta Catalan (Spain) spoke about ‘Carotid atherosclerosis in asymptomatic newly diagnosed type 2 diabetic subjects (NEWDM)’. Sander van Doorn (The Netherlands) presented his data on ‘Anticoagulant guideline adherence and reasons to deviate in patients with atrial fibrillation managed in primary care’. Gunnar Nilsson (Sweden) shared his result on ‘Diagnostic characteristics and prognosis of primary care patients referred for clinical exercise test: a prospective observational study’. Prof Christos Lionis presented the data of Dimitra Sifaki-Pistolla on ‘GIS 3D prediction mapping and network analysis applied on ischemic heart mortality in Greece: A tool for “smart” primary health care’. Geoffrey Watman (United Kingdom) spoke about ‘Clinic to Implement Patient Change from an Angiotensin Receptor Blocker (ARB) to an Angiotensin Converting Enzyme Inhibitor (ACEI) in General Medical Practices (GMP)’. Prof Jan Glatz concluded the session by presenting data of Robert Willemsen (The Netherlands) on ‘Heart-type Fatty Acid Binding Protein compared to high-sensitive Troponin T for early exclusion of acute myocardial infarction’.
On the second day of the meeting another session of rapid clinical updates since the last EPCCS meeting was held, in which Prof.dr. David Fitzmaurice (Birmingham, UK) spoke about AF and VTE guidelines. He pointed out that no placebo-controlled trials have laid at the basis for current treatment strategies, and recommendations are consequently rather unspecified.
Prof.dr. Martin Scherer (Hamburg, Germany) discussed developments in CV risk guidelines, focussing on CV risk management as a life-long task. A long-term doctor-patient relationship is needed, which implies an important task for primary care. The risk-age concept is new in CV risk guidelines, as well as the importance of psychosocial risk factors. A limited role is given to novel risk biomarkers.
Prof.dr. Frans Rutten (Utrecht, The Netherlands) spoke about the role of primary care in the treatment of angina pectoris. He highlighted the importance of time; what needs to be done when to ascertain a diagnosis of angina pectoris. Given the dynamic nature of the underlying atherosclerosis, treatment should likely differ across time points, and be fine-tuned for individual patients.
Prof.dr. Roland Schmieder (Erlangen, Germany) described the beneficial effects of renal denervation in truly resistant hypertensive patients, as well as promising data from small trials that tested renal denervation in patients with other conditions beyond hypertension.
In the last plenary session of the meeting, Prof.dr. Paul Aveyard (Oxford, UK) gave two talks on lifestyle changes. He started with giving advice on how to help patients lose weight. A high BMI is associated with an increased CV risk, mainly due to a high blood pressure and unfavourable lipid profile. Obesity at a younger age very likely results in diabetes at a larger age. Although there are very few treatments that yield long-term weight reduction, evidence exists that the length of time one is obese is what matters for health. Hence, even modest temporary weight loss, thus decreased exposure to metabolic disturbances of excess fat in the body, can yield health benefits.
Professor Aveyard then moved on to ways to help patients to quit smoking. He stressed that stopping with smoking is worth the effort, even after 60 years of exposure. Light smoking is also bad for the circulation. He advocated that GPs should talk to their patients about smoking more often than is the case now. The natural success rate is very poor, thus repeated attempts to help patients to quit is important. Although failure may seem the norm, the benefit is large if it works out.
After the stimulating sessions with interactive discussions, the participants were still motivated to end the meeting with two workshops. In one, Dr. Frans Rutten (Utrecht, The Netherlands) zoomed in on ECG interpretation, while Dr. Monika Hollander (Utrecht, The Netherlands) guided a session in which cardiovascular dilemmas were discussed, in order to help decision-making when patients do not precisely fit into the picture drawn by the guidelines.
Slides of the preparations in the EPCCS meeting have been prepared for and will be shared for educational purposes by the presenters in the near future.