5 highlights from ESC Congress 2021

Tuesday, 31 Aug 2021

One of the largest cardiology conferences in the world, the annual meeting of the European Society of Cardiology (ESC 2021) was virtual this year, but still delivered many practice-changing presentations and study results. Here are some of the key sessions presented between 27-30 August. You can view content on demand  from the meeting here.

Australian Quadpill outdoes monotherapy in BP control

The use of a quadpill of ultra-low dose antihypertensives could help patients achieve better blood pressure control than standard dose monotherapy, according to the Australian-led QUARTET trial presented at ESC 2021.

The study assessed 591 patients on either the quadpill, containing 37.5 mg irbesartan, 1.25 mg amlodipine, 0.625 mg indapamide and 2.5 mg bisopropolol, or 150 mg irbesartan between 2017 and 2020.

It found quadpill patients had lower systolic BP (6.9 mm Hg reduction, 95% CI: 4.9–8.9, P < 0.0001) and greater BP control rates (76% versus 58%, relative risk [RR]: 1.30, 95% CI: 1.15–1.47; P < 0.0001), with less need for additional BP medications at 12 weeks’ review than those on monotherapy (15% versus 40%).

The effect was sustained to 52 weeks, with quadpill patients’ mean unattended systolic BP staying 7.7 mm Hg (95% CI: 5.2–10.3) below monotherapy patients’. Their BP control rates were also higher (62%, RR: 1.32, 95% CI: 1.16–1.50), despite uptitrating less frequently.

Only seven serious adverse events were seen in the intervention group and three in the control group at 12 weeks, according to the trial investigators, led by Professor Clara Chow of the University of Sydney.

“This trial has demonstrated the simplicity, tolerability, and effectiveness of a quadpill-based strategy compared with the common strategy of initial standard dose monotherapy,” they wrote.

“This new paradigm holds promise for achieving better blood pressure control for people with hypertension around the world,” they concluded.

Immediate angiography no better than delayed strategy after OHCA

Immediate angiography post resuscitation from out-of-hospital cardiac arrest (OHCA) has no benefit over delayed or selective strategies, German researchers told the ESC 2021 meeting.

Their study reviewed 530 patients’ 30-day risk of death from any cause after receiving immediate, delayed or selective coronary angiography following resuscitation from out-of-hospital cardiac arrest without ST-segment elevation.

They found 54% of immediate angiography patients and 46% of delayed angiography recipients died by Day 30 (HR: 1.28, 95% CI: 1.00–1.63, P = 0.06).

“Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause,” they concluded.

CAS vs CEI outcomes comparable in asymptomatic patients with severe carotid artery stenosis

In asymptomatic patients with severe carotid artery stenosis, serious complications are similarly uncommon after competent carotid artery stenting (CAS) or carotid endarterectomy (CEA) and the long-term effects of the two procedures on fatal or disabling stroke are comparable, a randomised trial has shown

In the ACST-2 study, 3625 patients with severe unilateral or bilateral carotid artery stenosis were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean five years.

Overall, 1% had disabling stroke or death procedurally and 2% had non-disabling procedural stroke.

Estimates of five-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33).

After combining relative risks for any non-procedural stroke in all CAS versus CEA trials, the risk was similar in symptomatic and asymptomatic patients (overall RR 1·11).

The study investigators concluded that trials of CAS versus CEA now provide better evidence than existed before that both procedures carry similar risks and provide comparable benefits.

“This does not address the question of whether, in addition to good medical therapy, a skilful carotid intervention would be appropriate, nor does it address the question of how much each procedure costs to health services or patients. It does, however, mean that doctors and patients have a freer choice of which procedure is more appropriate for individuals,” they wrote in the Lancet.

Call for removal of age-related blood-pressure thresholds from international guidelines

Age-related blood-pressure thresholds should be removed from guidelines, according to UK researchrs who found “compelling evidence” for the effectiveness antihypertensive treatment into old age irrespective of baseline systolic or diastolic BP.

Their study analysed participant-level data from 51 large-scale trials of BP treatment. Involving almost 360,000 people, including 20,000 over the age of 80.

It found blood pressure reduction to be effective across a wide range of ages with no evidence that relative risk reductions for prevention of major cardiovascular events varied by baseline systolic or diastolic blood pressure levels, down to less than 120/70 mm Hg.

The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic BP were 0·82 in individuals younger than 55 years, 0·91 in those aged 55–64 years, 0·91 in those aged 65–74 years, 0·91 in those aged 75–84 years, and 0·99 in those aged 85 years and older. Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure.

While there was diminishing relative risk reductions with increasing age, the researchers noted that absolute risk reductions for major cardiovascular events were larger in older groups.

The study authors concluded that antihypertensive medication “should be considered as an important treatment option for the prevention of cardiovascular events even in those aged 80 years or older and guidelines should be simplified to remove any differing blood pressure thresholds by age.

“These findings challenge the common approach of withholding antihypertensive treatment for older adults, in particular when their blood pressure is not highly abnormal,” they wrote in the Lancet

“Treatment should, therefore, be considered an important option regardless of age with removal of age-related blood-pressure thresholds from international guidelines.”

HF events reduced by haemodynamic guided management

Haemodynamic guided management may reduce heart failure events in patients with earlier stage heart failure, according to results from a North American study.

The GUIDE-HF trial produced findings suggesting that the use of an implantable pulmonary artery pressure monitor reduced HF hospitalisations in patients with moderately symptomatic (NYHA functional class II) chronic heart failure.

However the overall results from the trial did not reach statistical significance, possibly due to disruption caused by the COVID-19 pandemic, the US investigators told the ESC 2021.

The study conducted at 118 centres in the US and Canada enrolled 1000 patients with with all ejection fractions, NYHA functional class II–IV chronic heart failure, and either a recent heart failure hospitalisation or elevated natriuretic peptides. In the intervention group patients were managed with CardioMEMS a wireless sensor implanted into the pulmonary artery via a right heart catheterisation procedure to transmit pulmonary artery pressures. Pressure data were used by clinicians to titrate heart failure medications in order to control congestion.

The primary endpoint was a composite of all-cause mortality and total heart failure events (heart failure hospitalisations and urgent heart failure hospital visits) at 12 months.

In the pre-COVID-19 impact analysis, the rates of primary heart failure events were 0·553 per patient-year in the remote pulmonary artery pressure monitoring intervention group and 0·682 per patient-year in the control group (HR 0·81, 95% CI 0·66–1·00; p=0·049).  However this difference almost disappeared during COVID-19, with no difference between groups (HR 1·11, 95% CI 0·80–1·55; p=0·53).

The cumulative incidence of heart failure events was not reduced by haemodynamic-guided management  in the overall study analysis (HR 0·85, 0·70–1·03; p=0·096) but was significantly decreased in the pre-COVID-19 impact analysis (0·76, 0·61–0·95; p=0·014). Neither urgent heart failure visits nor mortality were reduced independently with treatment in the overall or pre-COVID-19 analyses.

“The findings indicate that the benefits of haemodynamic guided management in reducing heart failure hospitalisations extend to patients with less severe heart failure (NYHA class II) and to those with NYHA II and III symptoms and elevated natriuretic peptides but no previous hospitalisation,” noted study investigator Professor JoAnn Lindenfeld of Vanderbilt University Medical Center.

The NYHA class IV heart failure patients did not show consistent results but were small in number, she added.

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