Practice Update - ESC Congress 2017

(EAS) guidelines, which advocate pursu- ing LDL cholesterol treatment targets defined based on a patient's risk. Many studies, however, have shown that in real-life practice, the rate of achieving an LDL cholesterol target of <70 mg/dL for very high risk patients in secondary prevention is only 20–25%. Dr. Gitt said, “Observational trials in many fields of cardiology have shown that female patients are less likely to be treated according to current guidelines. We therefore raised the question of whether female sex exerts an impact on reaching the LDL cholesterol target of <70 mg/dL for secondary prevention in clinical practice.” DYSIS II assessed the proportion of male and female patients who achieved treat- ment targets in clinical practice. Between 2008 and 2012, 57,855 consecutive out- patients treated with statins were enrolled. Data was collected on cardiovascular risk factors, statin treatment and dose, and with beta-blocker), and cardiac resynchro- nization therapy. RACE 3 included 250 patients with symp- tomatic early persistent atrial fibrillation and early mild-to-moderate heart failure who were scheduled for electrical car- dioversion. All patients received causal treatment of atrial fibrillation and heart failure and were then randomized to conventional guideline-based rhythm control with or without an additional four risk factor-driven upstream therapies. The upstream therapy group received: 1. Cardiac rehabilitation including phys- ical activity, dietary restriction, and regular counseling on drug adher- ence, exercise maintenance, and dietary restriction 2. Mineralocorticoid receptor antagonists 3. Statins 4. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers Upstream therapies started at least 3 weeks before electrical cardioversion and were continued for 12 months. Every effort was made to titrate all drugs opti- mally. If atrial fibrillation relapsed, repeat cardioversions, antiarrhythmic drugs, and atrial ablation were allowed. The primary endpoint was the presence of sinus rhythm after 1 year of follow-up, assessed with continuous 7-day Holter

Dr. Rienstra concluded, “Upstream rhythm control, including meticulous treatment of risk factors and change in lifestyle, is effective, feasible, and safe in improving maintenance of sinus rhythm in patients with early short-lasting atrial fibrillation and early mild to moderate heart failure. Upstream therapies also improved the treatment of cardiovascular risk factors.”

monitoring during the last week of the study. Secondary endpoints included atrial size, left ventricular function, exercise capacity, hospitalization for heart failure and other reasons, mortality, quality of life, and side effects of upstream therapies. At 1 year follow-up, sinus rhythm was present in 89 of 119 (75%) patients in the upstream therapy group vs 79 of 126 (63%) patients in the control group (P = .021). No difference in antiarrhythmic drug use or the number of electrical cardioversions was observed between the two groups.

PracticeUpdate Editorial Team

© ESC Congress 2017 – European Society of Cardiology

Women were more often treated with less potent, as well as lower doses, of statins, independent of the statin used. Only 17.5% of women reached the LDL cholesterol target of <70 mg/dL vs 24% of men (P < .001). Even after correcting for differences in baseline characteristics, female sex inde- pendently predicted failure to achieve the LDL cholesterol target in clinical practice (odds ratio 0.68; 95% confidence interval 0.47–0.97). Dr. Gitt concluded, “Women at very high risk of a cardiovascular event were treated with less potent, and lower doses, of statins than men in clinical practice. Compared with men, women were at a 32% lower chance of reaching the LDL cholesterol target recommended by ESC/ EAS guidelines. More research is needed to discover why women are treated inadequately to avoid preventable cardi- ovascular events.”

LDL cholesterol level. All information was obtained under real life conditions in an outpatient setting. Each patient’s risk of a cardiovascular event was calculated using the ESC Systematic COronary Risk Evaluation (SCORE) risk charts. The researchers then examined the asso- ciation between female sex and achieving an LDL cholesterol level of <70 mg/dL in patients at very high risk of a cardiovas- cular event. A total of 46,310 patients in the study were at very high risk of a cardiovascular event, of whom 18,653 (40.3%) were women. Compared to men, female patients were older, more often harbored risk factors such as hypertension and diabetes, and less often suffered frommanifest ischemic heart disease. Body mass index was 27.7 ± 5.8 kg/m 2 in both men and women. A total of 79.4% of women and 75.6% of men had hyperten- sion (P < .001). A total of 55.3% of women and 47.0% of men had diabetes (P < .001).

PracticeUpdate Editorial Team

15 ESC Congress 2017 • PRACTICEUPDATE CONFERENCE SERIES