Practice Update - ESC Congress 2017

Risk Factor-DrivenUpstreamAtrial Fibrillation Therapy Improves Sinus RhythmMaintenance Risk factor-driven upstream rhythm control has been found to be effective, feasible, and safe in improving maintenance of sinus rhythm in patients with early short-lasting atrial fibrillation and heart failure. The novel therapy included meticulous treatment of risk factors and change in lifestyle and was superior to conventional guideline-based rhythm control. This result of the international, investigator-initiated, multicenter, prospective, open-label Routine vs Aggressive risk factor driven upstream rhythm Control for prevention of Early atrial fibrillation in heart failure (RACE 3) trial was presented at the 2017 European Society of Cardiology (ESC) Congress, from August 26–30.

M ichiel Rienstra, MD, PhD, of the University Medical CentreGroningen, TheNetherlands, explained, “Atrial fibrillation is the most common sustained cardiac arrhythmia and affects millions of people in Europe. Patients suffer from palpitations, shortness of breath, impaired exer- cise tolerance, and poor quality of life and are at increased risk of stroke, heart failure, and death.” In most patients, atrial fibrillation is in part caused by comorbidities such as hypertension, heart failure, and obesity. Atrial fibrillation is a progres- sive disease and despite available medical and interventional therapies, long-term maintenance of normal (sinus) rhythm is cumbersome. Atrial fibrillation and its progression are caused by structural remodeling of the left atrium. Upstream rhythm control therapy may modify atrial remod- eling and help prevent atrial fibrillation and its progression.

RACE 3 was designed to test the hypothesis that risk factor-driven upstream therapy is superior to conventional therapy for maintenance of sinus rhythm at 12 months in patients with early persistent atrial fibrillation and heart failure. Inclusion criteria were early symptomatic persis- tent atrial fibrillation, mild to moderate early heart failure, optimal documentation and treatment of underlying heart disease, no contraindications to oral anticoagulation, eligibility for cardiovascular rehabilitation, and age ≥40 years. Exclusion criteria were being waitlisted for pulmo- nary vein isolation or expected to be waitlisted within 1 year, class IV New York Heart Association heart failure, left ventricular ejection fraction <25%, left atrial size >50 mm (parasternal axis), aldoster- one receptor antagonist use, previous use of class I or III antiarrhythmic drugs (except for sotalol, which should be discontinued at inclusion and replaced

Dr. Michiel Rienstra

WomenAre Less Likely ThanMen toReceive Recommended StatinDoses

Women at high risk of cardiovascular events have been found to be less likely to receive recommended statin doses for secondary prevention. This conclusion, based on results of the multinational cross-sectional Dyslipidaemia International Study II (DYSIS II) in Europe, Canada, South Africa, the Middle East, and China, was presented at the 2017 European Society of Cardiology (ESC) Congress, from August 26–30.

A nselm Kai Gitt, MD, of the Heart Centre Ludwigshafen, Germany, explained that the importance of lowering low-density lipopro- tein (LDL) cholesterol is undisputed, with research demonstrating that a decrease of 1 mmoL/L (39 mg/ dL) may reduce the 5-year risk of major coronary events, need for revascularization, and stroke by approximately one-fifth. Additional decreases improve outcomes even more. Because LDL cholesterol is a major contributor to cardiovascular disease, DYSIS II set out to deter- mine LDL cholesterol target value attainment, use of lipid-lowering therapy, and cardiovascular outcomes

in patients with stable coronary heart disease and those suffering from an acute coronary syndrome. Conclusions of DYSIS II were that attainment of LDL cholesterol targets was extremely low in patients with very high risk coronary heart disease and acute coronary syndrome, statin dosages were not max- imized, with combination therapies used scarcely, and hyperlipidemia was undertreated on a global scale. The reduction in major coronary events from lowering LDL cholesterol is reflected in European Society of Cardiology (ESC)/European Atherosclerosis Society

Dr. Anselm Kai Gitt

14 PRACTICEUPDATE CONFERENCE SERIES • ESC Congress 2017