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Editorial - December 2021

ESC Working Group on Cardiovascular Pharmacotherapy



Dear Members,

In this Newsletter we would like to focus on some unsolved pharmacological issues with cardiology. In the following short extracts of some of these issues will be highlighted.

The role and selection of antithrombotic therapy to improve limb outcomes in chronic lower extremity artery disease (LEAD) has previously been reviewed in the journal.1 In this issue of the journal, Bongard and co-workers from France have assessed the association between angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) prescription at discharge in patients hospitalized for symptomatic LEAD and 1-year mortality in a cohort study, which included consecutive patients hospitalized for symptomatic LEAD in four French academic centres. The authors concluded that ARB at discharge after hospitalization for symptomatic LEAD was associated with better survival compared with ACEI or no ACEI/ARB.

Joo and co-workers investigated the association between beta-blocker therapy and clinical outcomes in patients with acute myocardial infarction (AMI), especially with mid-range or preserved left ventricular systolic function. These data suggested that long-term beta-blocker therapy may be guided by LVEF. Similar results have been presented in other retrospective studies.2,3 Hopefully, the RC trial REBOOT4 will guide us in the future.

Nielsen and co-workers from Denmark determined the risk of major cardiovascular events (MACEs) and death, associated with an early large and rapid decline in HbA 1C following first-time initiation of an oral anti-diabetic drug (OAD). They concluded that a combination of a high pre-treatment HbA 1C and a steep decline in HbA 1C was associated with a decreased short-term risk of MACEs.

In another epidemiologic study from Denmark, Schmidt and co-workers examined whether prescription patterns complied with recommendations not to use non-steroidal anti-inflammatory drugs (NSAIDs) in patients with cardiovascular contraindications.5,6 The authors reported that initiation of NSAIDs in patients with cardiovascular disease has declined since 2002. Shorter treatment duration, declining COX-2 inhibition, and increasing use of naproxen and low-dose ibuprofen suggest adherence to guidelines when NSAIDs cannot be avoided.

Statin adherence is an important issue when treating patients at cardiovascular risk.7,8 Munkhagen and co-workers estimated the effect of atorvastatin on muscle symptom intensity in coronary heart disease (CHD) patients with self-perceived statin-associated muscle symptoms (SAMSs). The conclusion was that rechallenge with high-intensity atorvastatin did not affect the intensity of muscle symptoms in CHD patients with self-perceived SAMSs during previous atorvastatin therapy and there was no relationship between muscle symptoms and systemic exposure to atorvastatin and/or its metabolites.

Hypokalaemia is common in patients with cardiovascular disease.9,10 In a review paper from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy, the authors emphasize the importance of tight potassium regulation in patients with cardiovascular disease based on findings from observational studies.

We also recommend the Pharmapulse Section of the journals November issue, where new trial evidence from the HFA/ESC Heart Failure Congress 2021 and European Society of Cardiology Congress 2021 are commented. The ESC Congress 2021, although still online due to the Covid-19 pandemic, was an extraordinary theatre for the presentation of practice-changing trials and of the new 2021 ESC Guidelines on HF, which will shape the management of heart failure (HF) over the next years. During the congress several important new guidelines were presented, and among them the much anticipated ones on HF.11 In terms of pharmacotherapy, the SGLT2i dapagliflozin and empagliflozin now represent one of the pillars of HFrEF pharmacotherapy together with renin-angiotensin-aldosterone system inhibitors (RAASi), beta-blockers, and sacubitril/valsartan, which all have now Ia recommendation in HFrEF to reduce HF hospitalization and death. Vericiguat has now IIb recommendation in HFrEF patients with NYHA class II–IV who have had worsening HF despite optimal HFrEF therapy. Finally, there is formal IIb recommendation for using RAASi, beta-blockers, and sacubitril/valsartan in patients with HFmrEF. Treatment of iron deficiency with ferric carboxymaltose has now also a IIa recommendation in symptomatic patients with HF recently hospitalized for HF and with EF ≤ 50%.

In relation to our educational courses detailed information regarding programs are available on our webpages.

The Pharmacotherapy in Older People course was successfully held online the 14th-15th October 2021. It is an engaging and interactive course to improve the professional knowledge and skills on cardiovascular pharmacotherapy in older patients.

The All About Clinical Trials course will be running on 16th-17th December 2021. This event will provide a deep insight into the long journey which brings pharmacological compounds from bench to bedside, i.e. from trial design for testing new drugs (generation of evidence and its critical appraisal) to implementation of pharmacological treatments for daily use in science and patient care.

We are launching a new educational programme: Cardiovascular Pharmacotherapy in women, which will be held online 17th-18th February 2022. The course will address unmet needs and knowledge gaps in the management of cardiovascular disease in women and aims at providing a balanced and practical view on the topic. Particular emphasis will be put on gender specific risk factors, dosing, evidence-based treatments and prevention of disease.

EuroCVP was successfully held online 10th-12th June 2021 and gave the best from our longstanding "All About Clinical Trials" course, to improve skills in designing and planning successful clinical trials. Moreover, profound discussions and expert panels enriched the record-breaking "Pharmacotherapy in Older People" course, to deliver better, personalized therapy for older patients. In addition to the highly successful course program, the designated highlight sessions provided an overview on pharmacotherapy and COVID-19, current challenges in pharmacogenomics, or on how to manage post-operative anti-thrombotic therapy after cardiovascular surgery.

Cardiovascular Pharmacotherapists and Trialists of Tomorrow (CPTT) is the Young community of the ESC Working Group on Cardiovascular Pharmacotherapy, dedicated to young professionals under 40 yeras (physicians, nurses, scientists or others) with a special interest in cardiovascular pharmacotherapy and clinical trials. The benefits of joining the CPTT are many and we encourage you to join, it is free of charge and you only need to be a member of the WG Cardiovascular Pharmacotherapy. Apply now.

On behalf of the Working Group nucleus,
Alexander Niessner, Chairperson 2020-2022 and
Anne Grete Semb, Communication Coordinator 2020-2022

References

  1. Savarese G, Reiner MF, Uijl A, D'Amario D, Agewall S, Atar D et al. Antithrombotic therapy and major adverse limb events in patients with chronic lower extremity arterial disease: systematic review and meta-analysis from the european society of cardiology working group on cardiovascular pharmacotherapy in collaboration with the european society of cardiology working group on aorta and peripheral vascular diseases. Eur Heart J Cardiovasc Pharmacother 2020;6:86–93.
  2. Montenegro Sá F, Morais J. A gradient of benefit of beta-blockers in acute coronary syndrome patients: from severely depressed ejection fraction up to the normal level. Eur Heart J Cardiovasc Pharmacother 2019;5:181–182.
  3. Dahl Aarvik M, Sandven I, Dondo TB, Gale CP, Ruddox V, Munkhaugen J et al. Effect of oral β-blocker treatment on mortality in contemporary post-myocardial infarction patients: a systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2019;5:12–20.
  4. Rossello X, Raposeiras-Roubin S, Latini R, Dominguez-Rodriguez A, Barrabés JA, Sánchez PL et al. Rationale and design of the pragmatic clinical trial tREatment with Beta-blockers after myOcardial infarction withOut reduced ejection fracTion (REBOOT). Eur Heart J Cardiovasc Pharmacother 2021:pvab060. doi: 10.1093/ehjcvp/pvab060.
  5. Olsen AS, McGettigan P, Gerds TA, Fosbøl EL, Olesen JB, Sindet-Pedersen C et al. Risk of gastrointestinal bleeding associated with oral anticoagulation and non-steroidal anti-inflammatory drugs in patients with atrial fibrillation: a nationwide study. Eur Heart J Cardiovasc Pharmacother 2020;6:292–300.
  6. Agewall S. Minimizing bleeding events. Eur Heart J Cardiovasc Pharmacother 2020;6:271–272.
  7. Zeitouni M, Sabouret P, Kerneis M, Silvain J, Collet JP, Bruckert E et al. 2019 ESC/EAS guidelines for management of dyslipidaemia: strengths and limitations. Eur Heart J Cardiovasc Pharmacother 2021;7:324–333.
  8. Drexel H, Coats AJS, Spoletini I, Bilato C, Mollace V, Perrone Filardi P et al. An expert opinion paper on statin adherence and implementation of new lipid-lowering medications by the ESC working group on cardiovascular pharmacotherapy: barriers to be overcome. Eur Heart J Cardiovasc Pharmacother 2020;6:115–121.
  9. Hagengaard L, Søgaard P, Espersen M, Sessa M, Lund PE, Krogager ML et al. Association between serum potassium levels and short-term mortality in patients with atrial fibrillation or flutter co-treated with diuretics and rate- or rhythm-controlling drugs. Eur Heart J Cardiovasc Pharmacother 2020;6:137–144.
  10. Marciniak TA. What are the pharmacodynamics of loop diuretics? Eur Heart J Cardiovasc Pharmacother 2019;5:246–248.