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Joint Symposium CCP / PPKF: Summary

Topic: Chronic Stable Angina

On 18 June 2009, for the first time in its history, the ESC Council for Cardiology Practice took part in a joint session with the Norwegian Society of Cardiology and with the Privat Praktiserende Kardiologers Forum at the Spring Meeting of the Norwegian Society of Cardiology.

Some facts about Tromsø 

Tromsø city is the ninth largest urban area in Norway by population. The area has been inhabited since the end of the Ice Age, and the Sámi culture is the first known culture of the region. Most of Tromsø, including the city centre, is located on the small island of Tromsøya in the county of Troms, 350 kilometres (217 miles) inside the Arctic Circle. The midnight sun, that you can see from Tromsø, is above the northern horizon from about 18 May to 26 July.

The Arctic Cathedral, a modern church from 1965, is probably the most famous landmark in Tromsø. The Polar Museum, situated in a wharf house from 1837, presents Tromsø's past as a centre for Arctic hunting and the starting point for Arctic expeditions.

More than 100 nationalities are represented in the population; among the more prominent minorities are the Sami, Russians, and Finns, both the local Kvens and immigrants from Finland proper.

The city is a cultural centre for its region, with several festivals held in summer.
The University of Tromsø is the world's northernmost university. It was established in 1968, and opened in 1972. It is the largest research and educational institution in northern Norway. The University's location makes it a natural venue for the development of studies of the region's natural environment, culture, and society.
The main focus of the University's activities is on the Auroral light research, Space science, Fishery science, Linguistics, Multi-cultural societies, Sami culture. The main medical fields are telemedicine, biotechnology, social medicine and a wide spectrum of Arctic research projects.

Joint symposium ESC Council of Cardiology Practice / Privat Praktiserende Kardiologers Forum during the Spring Meeting of the Norwegian Society of Cardiology

The Congress of the Norwegian Society of Cardiology took place in the Rica Ishavshotel from 18-20 June. The first session was the joint symposium of the ESC Council for Cardiology Practice (CCP) and the Privat Praktiserende Kardiologers Forum (PPKF) of Norway. Chairpersons were Prof. Alf Inge Larsen, Secretary of the Norwegian Society of Cardiology Board, and Prof. Giuseppe Germano, Chairman of the ESC CCP, with the active involvement of about eighty delegates.

After a pleasant musical intermezzo of folk songs, Prof. Germano gave a short presentation of the European Society of Cardiology and the Council for Cardiology Practice including:

  • the Council's programme "Cardiology Practice in Europe": a series of meetings from spring 2009 to spring 2010 during important Congresses of the National Societies of Cardiology. The programme will focus on the same topic (ischemic heart disease) in order to compare the situation in different countries.
  • and the Spring Meeting of Cardiology Practice in February 2010 that will be held via video-conference with several European countries.

Dr. Per K. Rønnevik then gave a short presentation of cardiologists in private practice in Norway (Privat Praktiserende Kardiologers Forum - PPKF). Of about 200 cardiologists working in Norway, around 30 are in private practice, mainly in the west of the country near Bergen, and the majority are members of the PPKF and of the Norwegian Society of Cardiology.

Several presentations followed, all focused on chronic stable angina.

Dr Per Anton Sirnes, Vice-Chair of the ESC CCP and former President of the PPKF presented “What is the current gold standard for optimal treatment? Chronic Stable Angina: What is the status of ESC guidelines? What is current optimal non-interventional treatment?" He showed how, after the publication of the ESC Guidelines on Stable Angina, many important studies on this topic have been published, and the need for an update is evident. Other issues were:

  • the transitions during the natural history of the illness to acute coronary syndromes
  • sudden death and heart failure
  • how the outcome of stable angina is influenced by risk factors such as hypertension
  • diabetes and previous myocardial infarction
  • and the targets of the therapy i.e. reduction of death risk and improvement of quality of life reducing symptoms.

In his conclusion Dr Sirnes analyzed the role of medical therapy, mainly new agents like ivabradine, ranolazine, nicorandil and fasudil, and allopurinol, and their costs versus PCI and CABG. The role of training and physical rehabilitation was also discussed. Moreover in the ensuing "questions and answers" sequence, delegates focused mainly on the aspects of exercise rehabilitation (see movies 2386-2391).

Prof. Sigmund Silber from Munich spoke on “When to revascularize or have the COURAGE to defer another angio? Are the ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for revascularization applicable to European practice for chronic stable angina?”

After an introduction on the Guidelines, pointing out the meaning of Class III recommendations that may be confusing (doesn’t an intervention work or is it contraindicated?), Prof. Silber explained that appropriateness is based on the criteria designed to examine the use of diagnostic and therapeutic procedures to support efficient use of medical resources during the pursuit of quality medical care.
Appropriateness criteria are based on expert opinions including non-medical and health care related people. They are helpful for diagnostic methods where usually no randomized data exists.
American scientific associations developed 180 clinic scenarios for the criteria of revascularization, scoring from 7 to 9 the indicated situations, from 4 to 6 the situations in which a revascularization may be effective and from 1 to 3 the non indicated situations, but without contraindications to revascularization.
Commenting the COURAGE trial, he underlined that in the ESC Guidelines on Percutaneous Coronary Interventions published long before the Trial, in patients with no or mild symptoms, the scenario is unlikely to be improved  by PCI, and only when there is evidence of large ischemia the recommendation class is IA. Prof. Silber then discussed the type of revascularization, focusing on the Sintax Trial results, on the Sintax Score of coronary lesions and on the preference for CABG over a score of 33.

Prof. Jan Erik Nordrehaug from Bergen presented “What is the Norwegian current practice of intervention in chronic stable angina? Are we following Europe?” He showed that the number of procedures, both PCI and CABG, in Norway are over the mean of OECD countries, illustrating the volumes of activity of Norwegian cath labs and of cardiac-surgery centres, focusing on the results and the mortality rate, influenced by the growing age of patients treated and by their complexity.

The last presenter was Dr. Frank Sonntag from Hamburg, Past-Chair of the Council for Cardiology Practice, on the topic “Cardiology Practice in Europe. How should a patient with chronic stable angina best be investigated outside hospital and what is the reimbursement in various European countries?” (See movie 2418). After a brief introduction on the wide diffusion of ischemic heart disease throughout the world, Dr. Sonntag stated that the right way to tackle the problem is firstly by early diagnosis and secondly by good primary prevention.
The clinical diagnosis of definite angina pectoris, in accordance with ESC guidelines, is based on the presence of three criteria:

  1. substernal chest discomfort of characteristic quality and duration
  2. provoked by exertion or emotional stress
  3. relieved by rest and / or by GTN.

Atypical (probable) angina meets two of these criteria, while if only one or none of these criteria are present, the chest pain is not cardiac. Dr Sonntag showed the class of recommendation of non invasive tests for stable angina, highlighting that:

  • ECG Stress Test is only in class IB
  • non invasive CT- arteriography in low risk patients, or in positive Stress Tests, is not indicated (class IIb C)
  • sensitivity and sensibility of ECG Stress Test is not quite satisfying, well below that of Stress Image Tests, that however are not available in private practice in several European countries.

In fact:

  • all Private Practice cardiologists in Europe use clinical evaluation
  • nearly all use ECG Stress Test
  • from 50 to 100% can use ECO
  • only few can use Stress ECO
  • and only in cooperation with radiologists and with Hospital Practice cardiologists can they indicate a MSCT coronary scan and an angiography.

The results of a diagnostic tool has to be inserted in the flow chart of the evaluation of the patient with suspected angina pectoris, and must be consistent with the probability of illness.
In his conclusion Dr. Sonntag analyzed the type of reimbursement of diagnostic tests in several European countries, showing great differences in payment.
This was the conclusive speech of the joint session. It seems to have been highly appreciated by the delegates as shown by the attention of the audience and the high level of the final discussion.


The joint session of the ESC Council for Cardiology Practice and the PPKF proved to be a very promising cornerstone for the activity of the Council in Europe.