The ACCA Masterclass
ACCA organised its first Masterclass in the field of Acute Cardiovascular Care, a 2-day expert meeting, gathering high-level professionals to discuss, exchange and debate on the current state of practice, advancement and future challenges specific to the acute areas of cardiovascular care.
Programme directors, Prof. David Walker (ACCA Board member and committee chair) and Prof. Christiaan Vrints (Founder of ACCA, ex-officio Board member and EHJ-ACVC editor in chief) selected focused topics covering the critical phase of managing patients arriving at the hospital with an acute cardiac event:
Chest Pain: prehospital and in the emergency department; out of hospital cardiac arrest (OHCA), cardiogenic shock, acute heart failure and mechanical circulatory support; alternating debate sessions with lectures and case-based discussion.
The sessions comprised an expert panel, and the setup aimed to facilitate free discussion, thereby making this event a unique opportunity for interaction and discussion amongst experts regarding optimising patient outcomes, but additionally to challenge best practice, identify gaps in evidence and brainstorm regarding future trends.
The objective was to engage the audience in strategic discussions, update their knowledge with new directions and call on their contribution to the elaboration of reference papers and recommendations for the future of the specialty.
After 2 days of intense debate and discussions, the ACCA board extracted the following “Take home messages” that will serve to question the current practice, provide guidance to necessary studies and guidelines and bring a new vision regarding the best treatment for patients with acute cardiovascular disease.
A well balanced age breakdown with:
- 36% above 50
- 30% 40-50
- 34% under 40
Gender: Female: 31% vs Male: 69%
Profession: 84% cardiologists vs 16% other (intensivists, emergentists)
Chest Pain - Expert debate Session - Outcome
Chairs: M Lettino, H Bueno and K Huber
Expert panel: M Lettino, H Bueno, P Goldstein, NL Mills, K Huber, F Breuckmann, U Zeymer, C Müller
Report by M. Lettino
This session dealt with the diagnosis and management of chest pain – and in particular the benefits of chest pain units which have developed in some countries.
Clinical evaluation of a patient with chest pain is the first step toward the correct final diagnosis; typical chest pain is relatively easily recognizable, while atypical chest pain is a much more questionable definition and opens to misdiagnosis.
ECG recording remains the first-line diagnostic tool: the earlier the better. It is therefore highly recommended to take an ECG in the pre-hospital setting.
Biomarkers are the second step:
- The opportunity to check for troponin in the pre-hospital setting is questionable. In case of a very early diagnosis of acute coronary syndrome it could theoretically help to bring the patient as soon as possible to hospitals with cath lab for early coronary angiography (very early risk stratification, probably very few cases) but the risk of false negatives could be quite high in very early presenters.
- Biomarkers are key in confirming diagnosis of MI: ED doctors and Cardiologists should know which test is available in their hospital and select the appropriate rule-in/rule-out algorithm. This is in fact crucial in shortening waiting times in the ED and also in containing healthcare costs
- Biomarkers identify those high risk patients who benefit from an early/aggressive interventional strategy. he interpretation of biomarker values should not be done in isolation. These can only be done correctly together with an adequate clinical judgment and accurate ECG interpretation.
Chest pain units are present only in few European countries (Germany, Switzerland), where they have undergone a certification process. We do not necessarily need chest pain units everywhere, but there is definitely a need for shared protocols and policies between Emergency physicians and Cardiologists.
Out of Hospital Cardiac Arrest (OHCA) – Expert debate Session - Outcome
Chairs: C Hassager, P Goldstein, E De Maria
Expert panel: C Hassager, E De Maria , P Goldstein, J Belohlavek, A Cariou , SL Leonardi
Report by C. Hassager
The evidence base for OHCA management is currently inadequate. This session focused on what we know and the larger area that currently is managed by expert opinion without much evidence. New therapies were discussed
Nothing of what we do is really proven in good randomised trials – yet. However: Never give up when a OHCA patient arrives to the hospital.
Our ability to prognosticate within the first hours (days?) is poor. pH and lactate is related to mortality – but the overlap between survivors (with good neurological function) and those who die is considerable. Even patients with very low pH (ie <6,5…) may survive.
Very sick patients without ROSC may need ECMO (eCPR) to survive. Patients with ‘refractory cardiac arrest’ may be salvageable if we do everything: angio and PCI, TTM, eCPR etc. In Prague currently 22% of these patients survive.
They are doing a randomised trial on ‘doing everything’ vs usual care – 93 out of 160 refractory OHCA have been randomised so far – we will have to wait 2 more years for the final results.
We also have to be careful when we prognosticate later on. We must use a multimodality approach (Clinical, EEG, SSEP, CT, MR etc), and we should not do this before 72h.
A severe SIRS response is often seen in the first days after a OHCA. We do not know how to treat it. In the first 3 days the patients die of MOF and CS – later on neurologic causes of death predominate.
Early response from lay persons/minimally educated first responders may be the key to a better prognosis. The improved survival that we have seen during the last 1-2 decades is perhaps mainly due to two things:
- More patients are resuscitated faster with shorter no-flow time, and
- At the hospital we do not give up during the first 24h anymore.
Acute Heart Failure - Meet the experts Session - Outcome
Chairs: C J M Vrints, J Masip, O Dar
Report by C.Vrints
An update was provided on the diagnosis of patients with suspected acute heart failure and the results of clinical trials with innovative therapies for acute heart failure were discussed.
In patients who present with acute dyspnoea it may be very difficult to disentangle acute heart failure and chronic obstructive lung disease because of overlap in signs and symptoms. An ECG, blood tests and a chest X-ray on admission frequently are insufficient to provide an adequate diagnosis. Echocardiography and spirometry allow a more precise diagnosis but are not always readily available or feasible in emergency situations.
Urgent measurement of plasma BNP can be helpful if the diagnosis is uncertain.
Most dyspnoeic patients with acute heart failure have BNP values above 400 pg/mL, whereas values below 100 pg/mL have a very high negative predictive value for heart failure as a cause of dyspnoea. Plasma BNP concentrations between 100 and 400 pg/mL, are less sensitive or specific for diagnosing or excluding acute heart failure. Other diagnoses should therefore be considered in patients with plasma BNP concentrations in this range. When the diagnosis of acute heart failure is confirmed by BNP levels above 400 pg/mL the underlying heart disorder always should be determined by echocardiography and additional investigations.
Moreover, precipitating causes should always be identified based on CHAMP: acute Coronary syndrome, Hypertensive emergency, Arrhytmia, acute Mechanical cause and Pulmonary embolism.
Several innovative pharmacological therapies have been tested in clinical trials with rather great disappointment. Mechanical approaches to circulatory and renal support are being examined closely but not yet with convincing results.
In absence of a new game changing therapy for acute and chronic heart failure the major message is therefore to apply more consistently, more efficiently and without any delay the therapies that we know are working in short and long term management of acute and subsequent chronic heart failure.
A recent audit on the management of acute heart failure in the UK demonstrated indeed that much progress can be obtained by a better and more systematic application of the ESC guidelines.
Cardiogenic Shock - Expert debate session - Outcome
Chairs: J Stepinska, S Halvorsen, T Gershlick
Expert panel: J Stepinska, S Halvorsen, T Gershlick, H Thiele, J Masip, S Price, A Sionis
Report by J. Stepinska
This session looked at cardiogenic shock (CS). The mortality in cardiogenic shock (CS) is still very high. The most frequent cause of CS is acute myocardial infarction (AMI). Mortality in CS complicating AMI is very high: 40-70% despite the percutaneous coronary intervention (PCI), inotropic therapy and mechanical support.
Randomized controlled trials are lacking; we have no clear guidelines.
The Holger’s Thiele trial - CULPRIT-SHOCK address the question of optimal revascularization strategy in patients with multivessels disease and acute MI complicated by CS. CULPRIT-SHOCK is a controlled, international, multicentre randomized open label trial. The study compares two strategies: immediate multivessels PCI in patients with CS complicating the AMI vs only culprit lesion PCI. The results are expected before the end of the year.
The risk prediction of short-term mortality in CS was discussed based on the Card Shock trial. Card Shock was a prospective, observational, European, multinational cohort study prospectively enrolled more than 219 pts. Study was conducted between 2010 and 2012. ACS aetiology, age, previous MI, CABG, confusion, low left ventricle ejection fraction and blood lactate are independently associated with increased mortality.
Among vasopressors and inotropes, adrenaline alone or in combination is independely associated with worsening of cardiac and renal function and 90.day mortality. In the Card Shock trial, the combined use of noradrenaline with dobutamine or noradrenaline with levosimendan was associated with better prognosis. The randomized controlled studies in the field of vasopressors/inotropes are needed.
Mechanical ventilation is generally recommended as a ventilatory support in CS, but the non invasive ventilation in CS seems to be an option.
There is a need for a consensus document regarding whole spectrum of the CS process and interventions.
Mechanical Circulatory support in Cardiogenic Shock – Meet the experts session - Outcome
Chairs: S Price, R. Trimlett
Report by S. Price
The session presented the current state-of-the-art in acute mechanical circulatory support from the perspective of the cardiac surgeon and the interventional cardiologist, as well as a vision into the future for challenges with respect to these innovative supportive techniques.
The high mortality that persists in patients with cardiogenic shock, despite current interventions, provides an ongoing challenge for the cardiac intensivist, with mortality ranging from 30-50% depending upon the underlying aetiology. Increasing focus on extracorporeal support in adult patients has arisen from a combination of circumstances including increased awareness and skill in extracorporeal membrane oxygenation (ECMO) following the influenza pandemic, the development of novel percutaneous mechanical circulatory support devices, and the disappointing results in the IABP Shock-II study.
However, despite a significant increase in adult cardiac ECMO, there are no randomised controlled studies demonstrating survival benefit, and a huge number of challenges remain, including cannulation site and technique, the effects of non-pulsatility, monitoring the effects of extracorporeal support on ventricular physiology, anticoagulation, left ventricular offloading, and assessment of ventricular recovery (both right and left) in the presence of ongoing mechanical circulatory support.
Further, for those patients where ventricular function does not recover, the global lack of organ donors means that if ECMO becomes more widely adapted (both for cardiac arrest and cardiogenic shock), and survival on ECMO continues to increase, there will be significant numbers of patients who will be alive on extracorporeal support, but with no exit strategy other than long-term ventricular assist, or total artificial heart implantation.
With improving technologies come opportunities, and the field of long-term ventricular assist, although expensive, may provide benefits in terms of quality of life as well as survival, however, further evidence is required, and a repeat of REMATCH, but using current extracorporeal devices is probably overdue.
The field of mechanical circulatory support is expanding faster than any other area of cardiology, and yet to date there are no guidelines for selection of appropriate devices that are approved by national societies in the field. The potential for research, evidence and improved outcomes in patients with acute heart failure and cardiogenic shock is clear.
What comes next?
ACCA will now evaluate the outcome of the discussions from this first masterclass and see whether the format is popular for future meetings.
Initial feedback is positive about the venue and discussions and there seems to be enthusiasm for more interactive sessions going forward.
Acute Cardiovascular Care Association: A unique platform for multi-disciplinary exchange
The mission of ACCA is to improve the quality of care and outcome of patients with acute cardiovascular diseases, encompassing the complete care of patients from first medical contact until patient stabilization.
ACCA is the first and unique platform of scientific exchange in the field where a multi-disciplinary team can share knowledge and enhance educational skills towards one single goal.