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Inside the sessions

The chairperson gives you the inside view on the programme of their session at Acute Cardiovascular Care 2015.


 

Saturday 17 October 2015

ACCA School - J. Barrabes

The Acute Cardiovascular Care congress has a well-earned reputation as an excellent place to get high-quality continuing education on acute cardiovascular care and a unique arena where attendees can easily interact with colleagues from all over the world and discuss the hottest scientific advances in this field. This year, for the first time, the congress offered two workshops specifically aimed at enhancing the practical skills of the audience on significant issues in acute cardiovascular care. These hands-on sessions, proposed and organised with great enthusiasm by the Acute Cardiovascular Care Association’s Young cardiologists, were tutored by leading experts in each topic and especially aimed towards young attendees, although every participant can benefit from the educational offer.

The first workshop, tutored by Professor Christian Sitzwohl, from the Medical University of Vienna (Vienna, AT) dealt with theoretical and practical aspects of renal replacement therapy (RRT). The learning objectives are to know the indications for RRT, to learn how to set correctly a hemofilter machine in each clinical situation, and to know how to correctly interpret the messages and alarms of the device. Attention is paid to the practical management of different RRT modalities such as slow ultrafiltration, hemofiltration, hemodiafiltration and dialysis. Participants have the opportunity to train with hemofilter machines displayed in the room.

Link to session

Professor Mary White, from the Royal Brompton Hospital (London, UK) is in charge of the second workshop, focused on invasive mechanical ventilation. Also taking a very practical approach and with mechanical ventilators available in the room, the session provides the attendees with an introduction to the indications and modalities of invasive mechanical ventilation. The participants have the opportunity to get hands-on learning on how to adjust the main settings of a ventilator in the most common clinical situations and when and how to do the weaning process.

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Both Prof. Sitzwohl and Prof. White have a considerable expertise in the topics assigned to them, and have an outstanding educational background in hands-on teaching. We thank them for their kind willingness to help in this exciting initiative of the Young ACCA, and we also thank Maria Rubini-Gimenez for her enthusiastic coordination of this task. We also thank the manufacturers of the machines on display for their invaluable help in making these workshops possible.

End-stage heart failure - W. Grander

End stage heart failure is usually considered to be a condition of refractory heart failure and requires above all accuracy of this diagnosis. If this episode of illness is not seen as purely palliative care, referral to specialists permanently dealing with acute and chronic forms of low output syndromes is mandatory.

The first therapy level in a stepwise approach in acute or acute on chronic heart failure will almost always be the introduction of pharmacological interventions. However, it has been shown in recent large registries and studies that even with these medications that have been used for decades, there remains a great deal of misunderstanding and controversies.

The first presentation dealing with this pharmacological approach should outline the quite surprising differences in the eminence and evidence based experiences of inotropes and vasodilators or inodilators. Additionally, a side trip through the requirements of hemodynamic monitoring and its interpretation should help to understand the favourable or unfavourable hemodynamic results of these drugs, in the short and long term.

Unfortunately, the recent results of studies using intra-aortic balloon pumps yield little hope that this device will maintain its position as the standard device in the management of cardiogenic shock. Therefore, the bell heralding the use of ECMO sounds throughout the cardiological landscapes! Miniaturization of this device makes its application even more attractive. However, what are the real challenges of this device, known as a extracorporeal circulatory support with many formidable side effects. When should it be used, who should get it and most importantly, when not to use it, should all be addressed in the second session.

Mechanical assist devices are a cornerstone of therapy for end-stage heart failure. This surgical approach to assist the left and or right ventricle has become a “safe harbour” when no transplant organ is available, and it seems that this device serves as a bridge-to-transplant approach, but may be used as a bridge-to-decision as well. The requirements for this presentation might be questions like: is there a continuum in the use of ECMO and LVAD; when is the best time to insert BiVAD or LVAD; what are the physiological minimum standards for a safe and prognostically powerful insertion.

The last presentation will logically close with the best opportunity to help in refractory end-stage heart failure, namely transplant. The survival data are excellent, but there is a growing shortage of donors. As announced in the title, “an update in heart transplantation” would disclose this intriguing organ transplantation which is much more than just a palliative approach in heart failure.

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Neurologic emergencies and acute cardiac care - Y. Hasin

Over the last decade, cardiologists and acute cardiovascular care teams have become increasingly involved in the care of patients with vascular neurologic emergencies. Therefore, the organizing committee should be commended for dedicating a session to neurologic emergencies, to be held during the forthcoming Acute Cardiovascular Care 2015 meeting in Vienna (on the morning of the first day).

There are several reasons for the intimate connection between cardiology and ischemic neurologic emergencies:

  • Embolic stroke is related to pathology of the heart and great vessels.
  • Invasive cardiac interventions, i.e. percutaneous coronary intervention for acute coronary syndrome (ACS) (particularly using thrombus aspiration) or transcatheter aortic valve implantation (TAVI) are sometimes complicated by cerebral emboli.
  • The encouraging results of early combined fibrinolytic and mechanical intervention in stroke have prompted the adoption of techniques already established in cardiology, such as the use of networks and urgent vascular intervention.
  • The shortage of interventional neurologists and intensive neurological care units, and the expertise developed in the Intensive Cardiac Care Units has encouraged many Intensive Cardiac Care Units to assume responsibility for these patients.

The coming session will discuss topics such as stroke networks, selection of novel oral anticoagulants for the prevention of ischemic and hemorrhagic stroke, recommendations for the proper use of antithrombotic therapy following stroke, and acute intracerebral intervention. I am looking forward to an informative session that is likely to evoke heated discussion.

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ACCA Research Prize - I. Ahrens

Now entering its second year, the prestigious ACCA Research Prize in Acute Cardiovascular Care was awarded at the Acute Cardiovascular Care 2015 congress in Vienna.

The ACCA Research Prize session features the four finalists who will present their unpublished work to the audience. This is definitely an event not to be missed. With over 50 submissions covering translational research, quality of care research and clinical outcomes research from research groups around world, the second edition of the ACCA Research Prize has already received world-wide recognition as the premier award in the field of acute cardiovascular care research.

For this year’s finalist session, the audience can expect outstanding presentations ranging from translational research to clinical outcomes research. The excellent projects to be presented by the four finalists will cover the topics of acute myocardial infarction and air pollution, as well as single biomarker strategies to rule out non-ST-segment elevation myocardial infarction. Furthermore, serum electrolytes, ventricular arrhythmias and ECG markers will be on the agenda, along with out-of-hospital cardiac arrest and therapeutic hypothermia.

We will learn from animal models how air pollution particulate matter aggravates acute myocardial infarction and heart failure via activation of alveolar macrophages. Specific inhibition of alveolar macrophage cytokine production may offer myocardial protection in patients with acute myocardial infarction in major urban areas with massive air pollution.

Rapid rule out strategies for myocardial infarction using a single biomarker have been suggested in selected patient cohorts. In a real world cohort of thousands of patients with acute coronary syndrome, a single biomarker approach with troponin I was successfully validated. We will learn about the cut-off value for this biomarker that would allow a negative predictive value of nearly 100%, and may therefore be highly valuable for triage of patients with suspected ACS in overcrowded emergency rooms.

From a large consecutive cohort of thousands of patients treated in cardiac care units, we will learn about the relationship of serum electrolytes, ventricular arrhythmias and QTc intervals. Furthermore, the concentration of serum ionized calcium and its relation with QTc prolongation and mortality will be revealed, and may offer the development of novel risk stratification schemes. 

The optimal temperature for hypothermia in targeted temperature management of patients with out-of-hospital cardiac arrest has been a topic of recent debate. From a study with nearly a thousand patients with out-of-hospital cardiac arrest and targeted temperature management, we will learn about the patient’s heart rate as a potential prognostic marker and the relation to target temperatures of 33° and 36°C.

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Cardiac arrest in the modern era - N. Nikolaou

This session  covers some of the most burning topics in the field of cardiopulmonary resuscitation. It is one of the first sessions after the release of the new 2015 European Resuscitation Council guidelines. Therefore, the audience is the first to hear the new guidelines on some of the most important topics in CPR science and practice from prominent experts.

Prof. Marco NOC (Ljubljana, Slovenia) opens the session by presenting some of the most recent advances and controversial topics in the treatment of victims of Out - Of Hospital Cardiac Arrest. Extracorporeal life support in refractory cardiac arrest, therapeutic hypothermia and optimal hemodynamic treatment are among the topics that he will address. Since at least one third of patients present with post-resuscitation cardiogenic shock, there is also the question of immediate hemodynamic support beyond inodilators and vasopressors. The role of intra-aortic balloon pumps and other ventricular-assist devices including Impella, Tandem Heart and ECMO will also be discussed.

Prof Leo BOSSAERT (Boechout, Belgium) discusses the 2015 science reviews and treatment recommendations of the International Liaison Committee of Resuscitation (ILCOR). The ILCOR includes all major resuscitation councils worldwide, and since 1992, has provided a forum for critical review of international resuscitation science. In the 2015 ILCOR process, the GRADE methodology was used as a uniform and accurate tool to evaluate the quality of the evidence. The 2015 Guidelines of the ERC are based on the ILCOR science review. Major changes will be briefly reported. The 2015 ERC guidelines for CPR are officially presented at the ERC congress (Prague 29-31 October), but will be published on 15 October 2015 together with the results of the ILCOR science review and are also available on line at (www.erc.edu).

Prof. Christian HASSAGER (Copenhagen, Denmark) discusses indications for immediately coronary angiography in comatose survivors of cardiac arrest. About 70% of all cardiac arrest patients have coronary atherosclerosis, and many have acute coronary syndromes. Furthermore, several retrospective studies have shown better survival among patients who undergo acute coronary angiogram compared to those who do not. This presentation will discuss whether this is a real effect of coronary revascularization or is whether it is due to selection bias. Remaining uncertainties and the need for further research will be highlighted.

Last but not least, Prof. Esteban LOPEZ DE SA Y ARESES (Madrid, Spain) presents the state of the art in neurologic prognostication of patients who remain comatose after return of spontaneous circulation (ROSC). Hypoxic-ischaemic brain injury is common after resuscitation from cardiac arrest. Two-thirds of deaths following ROSC after out-of-hospital cardiac arrest occur due to neurological injury. Accurate prognostication in these patients is critical, and every effort should be made to minimize the risk of falsely pessimistic prediction. Ideally, when predicting poor outcome, the false positive rate should be zero with the narrowest possible confidence interval

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Acute coronary syndromes in special populations - D. Walker

While the incidence of STEMI is falling in Europe, with a reduction in smoking and better treatment of risk factors generally, the incidence of NSTEMI is steadily rising. Unfortunately, these patients with NSTEMI are often older, frailer and have one or more co-morbidities to contend with, which makes decision making more difficult. Although risk stratification systems such as GRACE help us to prioritise patients for a more invasive strategy, inevitably, patients requiring intervention are also at high risk of complications.

In this fascinating session which I am chairing with Harold Darius from Berlin, we are privileged to hear 4 experts in the field speak to us about the management of NSTEMI in 4 high risk groups, namely anaemia, renal insufficiency, diabetes and cognitive impairment (including delirium, agitation).

These common co-morbidities raise significant management issues. Do you investigate the anaemia first – is this dangerous in the context of ACS – or is it more dangerous to give DAPT where there may be a duodenal ulcer, for example? At what level should you transfuse? Can you do anything to protect renal function prior to angiography? Is there a level of chronic kidney disease where the risk of intervention outweighs the possible benefits? How should you manage diabetes mellitus during admission? Are certain diabetic medications deleterious in the context of ischaemic heart disease? Do we really need to stop metformin prior to angiography?

Link to session

 

Sunday 18 October 2015

Is there a role for platelet reactivity testing in patients with coronary artery disease treated with P2Y12 inhibitors? - S.D. Kristensen

In this exciting session to be held at the Acute Cardiovascular Care 2015 congress in Vienna, Austria on 18th October 2015, four expert speakers will discuss the use of platelet assessment in patients with acute and chronic coronary disease.

The field is very important as platelet testing may be a way to identify patients treated with dual antiplatelet therapy at high risk of developing thrombosis or bleeding – both important, and sometimes fatal events in patients with coronary artery disease. Four experts in the field will address the use of platelet measurements in different clinical scenarios.

In his lecture entitled ‘Testing platelet reactivity in patients undergoing PCI to predict stent thrombosis: for whom?’, Prof Bonello (Marseille, France) will focus on how to assess poor response to P2Y12 inhibitors and provide advice on which patients should be tested. Should we reserve testing to patients with high risk lesions (such as left main stenting) or to high risk patients (e.g. diabetics) – should we test all patients, or none?

In his talk ‘Testing platelet reactivity in patients undergoing PCI to predict bleeding: for whom?’, Prof Sibbing (Munich, Germany) will focus on the other side of the coin: can we use testing to identify patients at high risk of bleeding? Should we test all patients on dual antiplatelet therapy for ‘hyper-response’ or should we focus on patients with a high bleeding risk, based on clinical criteria (e.g. elderly, low body weight, female patients, with decreased renal function).

Patients on dual antiplatelet therapy may need cardiac or non-cardiac surgery. Often, the surgeons prefer to operate on patients in whom platelet P2Y12 receptors are not blocked, and therefore we usually recommend that P2Y12 inhibitors be stopped for 4-7 days before surgery. In her lecture entitled ‘Testing platelet reactivity in patients planned for CABG to optimize the timing of surgery’, Prof Mahla (Vienna, Austria) will present data on the use of preoperative platelet testing and discuss whether this may be useful in some patients.

Finally, Prof Lev (Ramat Hasharon, Israel) will help us to understand the importance of platelet production and turnover in patients with coronary artery disease. His talk on ‘Testing for reticulated immature platelets as a marker of thrombotic risk’ will quote several recent papers reporting that mean platelet volume and the number or fraction of immature platelets are related to outcome, and also influence the effect of platelet inhibiting drugs.

The discussion during the session will be lively and will focus on how to measure platelet hyper-reactivity and whether we should use testing in our patients. Although trials on the use of platelet assessment for optimization of antiplatelet therapy have been somewhat disappointing, this fascinating field is still evolving.

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Diagnostic tools in the management of acute heart failure - G. Keren

Congestive heart failure is a leading cause of morbidity and mortality worldwide. The disease generally arises from dysfunction of the myocardium, either by systolic (HFREF), or diastolic dysfunction (HFPEF) or a combination of both. The pathopysiology of acute heart failure is complex and may vary according to the underlying cardiac disease, the associated vascular disease and other mechanisms. Patients with chronic heart failure may decompensate because of non-compliance with optimal therapy, or due to an acute ischemic event or systemic infection. Patients with normal cardiac function may develop acute heart failure secondary to an acute insult to the myocardium or severe valve dysfunction. Interestingly, among patients who are hospitalized with acute heart failure , the prevalence of those with preserved ejection fraction is high.

The hallmark of the clinical presentation of heart failure is congestion. Patients may present within a range extending from pulmonary oedema to extensive peripheral oedema, based on the underlying pathophysiology, the hemodynamic cardiac dysfunction, the tendency for fluid retention, and venous and lymphatic congestion in the lungs and periphery.

The assessment of the patient with acute heart failure starts with a comprehensive history and physical examination, focusing on basic hemodynamics, tissue perfusion, lung and peripheral oedema and urine output. The secretion of natriuretic peptides reflects cardiac wall stress in the atria and ventricles, and they are useful biomarkers for assessing clinical status and response to therapy. The interpretation of biomarkers results, bearing in mind the limitations and use in guiding patient management, is important for the treatment of patients with acute heart failure. Echocardiography is a useful clinical tool to assess cardiac function, and identify the underlying cardiac pathology. Echocardiography and Doppler provide non-invasive means to estimate cardiac output, determine filling pressures within the heart and define pulmonary artery pressure, and they are particularly useful for defining clinical response to therapy. Ultrasound, although limited by the presence of air within the lungs, has been shown to be useful in the assessment of lung pathologies, such as cardiogenic pulmonary oedema, pneumothorax, interstitial lung disease, pulmonary infarctions and contusions. The use of ultrasound in clinical practice at the bedside should be intensified.

Many non invasive measures to study the vascular system and water retention have been developed, based on bioimpedance technology, sound and pressure wave form analysis, and they are used in clinical practice for home monitoring of patients with heart failure. They can also be used at the bedside, obviating the need for routine use of invasive hemodynamic monitoring in these patients.

In this era, where multiple non-invasive methods to assess the cardiovascular system at the bedside exist, clinicians raise the obvious question of whether there still is a role for invasive hemodynamic monitoring. The answer, I think, is yes, although a worthwhile and interesting discussion would be to define in whom, and at what stage of patient assessment and critical care management invasive means should be used.

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Update in cardiac arrest - Access the slides from this session

 

K. Krycthtiuk, chairperson

The treatment of cardiac arrest remains a challenging field, in both the clinical and pre-clinical settings, and involving care-givers of various specialties. The key to success is the integration of everybody involved in the treatment of such patients into one dynamic network of clinical care from EMS dispatchers, paramedics, emergency room physicians and nurses to intensivists, invasive cardiologists and healthcare professionals involved in rehabilitation. This year’s annual Acute Cardiovascular Care 2015 congress in Vienna, Austria features a two-and-a-half day educational track including two practical hands-on sessions within the Acute Cardiovascular Care Association school, and a comprehensive update on various fields within acute cardiac care divided into six dedicated sessions. One of those sessions will be devoted to the treatment of cardiac arrest, and will take place on October 18 at 10:30 in the Gartensaal, where four experts will give an update on important topics within cardiac arrest care. Current guidelines by the European Resuscitation Council suggest the initiation of therapeutic hypothermia in all comatose patients immediately after return of spontaneous circulation (ROSC). Novel data including the widely discussed results of the Targeted Temperature Management (TTM) trial suggested that temperature control at 36°C is as good as hypothermia targeted at 33°C. These findings, as well as current guidelines and experience from daily clinical practice will be discussed and presented by Goran Olivecrona from Lund in Sweden. The long-lasting dispute on the clinical evidence for the use of adrenaline in cardiac arrest, as well as the role of monitoring and devices will be discussed by Tobias Graf from Lübeck, Germany. In tertiary care centers, extracorporeal membrane oxygenation (ECMO) is often implemented during cardiopulmonary resuscitation (CPR) in patients without ROSC as a last option. Walter Speidl from Vienna, Austria will present the latest evidence on ECMO use in CPR and share his personal experiences from a high-volume center. Post-resuscitation care remains a cornerstone in cardiac arrest care, since well-organized post-CPR care has been shown to be mandatory to achieve a beneficial outcome in patients. Georg Fürnau from Lübeck, Germany will highlight the most important aspects of post-resuscitation care, including the role of routine early coronary angiography after ROSC.

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Management of deep venous thrombosis/ pulmonary embolism - G. Lip

This will be an interesting session, which addresses challenges in the diagnosis and risk stratification of pulmonary embolism. Attendees would be expected to appreciate what is new and best practice, with reference to current guidelines on this topic.

The Novel Oral Anticoagulants (NOACs) have transformed the landscape for oral anticoagulation. Knowledge and gaps in relation to NOAC use will be covered within this session. Also, we need to know when, why and how to use thrombolysis in the setting of pulmonary embolism.

Finally, the session concludes with a presentation on the role of the surgeon. Pulmonary artery thrombectomy is uncommon these days, but again, we need to know where things stand.

We are looking forward to an educational and informative session.

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Organ dysfunction in acute heart failure - Access the slides from this session

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Monday 19 October 2015

Gender-specific issues in acute cardiovascular care - M. Lettino

Over the last ten years, many efforts have been made to increase recognition of the importance of cardiac disease in women, and to improve our undestanding of differences in sex/gender cardiovascular disease. Scientists, clinicians, policy makers and other professionals are involved in this process, with the aim of reducing gender disparities in research and clinical care.

In the setting of acute cardiovascular care, women more frequently receive poorer quality of care, formany reasons: they tend to call for medical attention later than men, and their symptoms are frequently atypical, often resulting in misdiagnosis and delaying appropriate therapy, which can eventually affect prognosis. The Acute Cardiovascular Care 2015 congress is an extraordinary opportunity to meet opinion leaders and scientists from different countries who will present their experience. This is of particular value in those fields where scientific production is not so prolific, and the topic sometimes neglected.

Acute coronary syndromes (ACS) and malignant arrhythmias in women are topics that are not extensively addressed by clinical research, even though female mortality is increasing from cardiovascular disease is on the increase. Despite the fact that almost all European guidelines covering acute cardiovascular diseases underline that women should be managed in the same way as men, this is mostly the opinion of experts, since women, specifically younger women, are very poorly represented in clinical trials.

During the session we will learn what is new in coronary revascularization for atherothrombotic disease in female patients, both in terms of vascular approaches and devices, and peri-procedural and long-term antithrombotic therapy. For both women and men, coronary heart disease (CHD) is the largest contributor to cardiovascular disease (CVD) morbidity and mortality. The absolute numbers of women living with and dying of CVD and stroke exceed those of men, and this is one of the reasons why we should improve our undestanding of the disease in order to improve female patient outcome. Moreover, data over the past decade have shown that women have higher 30-day mortality compared to men after an ACS episode, and it is now recognized that the gender differences are largely explained by clinical differences at presentation.

Concerning life-threatening arrhythmias, we will be updated about the gender disparities in opportunities for defibrillator implantation (ICD), because of a substantial underutilization of these devices in women, despite the indication, and bearing in mind that in men, there is often a problem of over-use. Moreover, we also expect to discuss some suggestions from clinical research that poor quality of life and psychological disturbances may be observed more often in female patients receiving ICDs than in their male counterparts. In fact, it has been reported that women more frequently develop depression after ICD implantation and therefore, need more psychological interventions during follow-up.

Finally, the historical issue of hormone replacement therapy will be addressed at the end of the session to outline where we currently stand, and how we can deal with the need for some women who develop a cardiovascular disease to be properly treated for gynecological reasons.

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Educational Track - Young ACCA

The dedicated, interactive programme of the educational track is designed for physicians who are in training in the wide and multi-disciplinary field of acute cardiac care.

The Young ACCA are keen to hear focused, practical advice for our everyday clinical work. We would like to learn how to manage patients with acute myocardial infarction, cardiac shock and cardiac arrest in dedicated educational sessions. Also, we consider it essential to learn how to manage arrhythmias in an acute setting, such as electrical storm. Finally, we would like to learn how to manage four of the most important hot topics in acute cardiovascular care, which are outlined hereafter.

  • Update in STEMI: Learn about optimal prehospital management and treatment (especially timelines and pre-hospital thrombolysis), interventional strategies for STEMI and identification and management of the main potential complications.
  • Update in NSTE-ACS:  Learn about diagnosis (high sensitivity troponin assays and other novel biomarkers), risk stratification, as well as pharmacologic and interventional therapy of NSTEMI patients. Get to know the highlights and recommendations of the new ESC Guidelines 2015 for the management of non-ST segment elevation ACS presented during the recent ESC anual congress in London.
  • Update in cardiac arrest: Learn to manage the different tools during cardiopulmonary resuscitation (e.g. adrenaline or devices); the role of, and indications for hypothermia and extracorporeal membrane oxygenation, as well as optimal management after resuscitation.
  • Update in cardiac shock: Learn about the pathophysiology of cardiogenic shock and multi-organ dysfunction, the different pharmacological options (including catecholamines), management of assist devices and the different questions related to revascularisation strategies in patients with cardiogenic shock.

As regards management of arrhythmias, we are eager to learn about diagnosis and management of the most frequent, but challenging arrhythmias in acute cardiac care and three interesting clinical cases will be presented by young cardiologists.

The hot topics should provide useful Information about diagnosis and management of the most challenging situations in acute cardiovascular care, such as pericardial tamponade, acute valvular disease, infective endocarditis, and acute aortic disease.