History of the ESC. Part 2. The big bang of European cardiology: 1992-2015

Table 1.  List of ESC presidents from 1992 to 2015.

Table 2. Expansion of the European Society of Cardiology: key data.

Opening of the European Heart House

The inauguration of the European Heart House (EHH), located on the French Riviera, on 31 August 1993 by President Michel Bertand was a milestone in the development and success of the ESC. The foundation stone was laid by Michel Bertrand and president-elect Philip Poole-Wilson in November 1992. The construction of the building started on a beautiful piece of land of 24,000 square meters and was completed within an incredibly short period of time. The futurist architecture of the building, designed by Charles-Jean Schmeltz, was unanimously praised, and this building became the symbol of the ESC and the pride of European cardiologists. This facility served two main functions: to act as headquarters of all ESC activities and to provide meeting rooms for the scientific activities of the different bodies composing the ESC. Retrospectively, this decision was visionary and, as time passed by, the EHH became a very busy hub for the multiple activities of the society, which eventually required some adaptation of the building in order to cope with the growing number of staff, activities, and meetings.

Clinical practice guidelines and registries

The ESC leadership realised that one annual scientific meeting was not sufficient to satisfy its mission, and to help cardiologists in their daily practice, it was becoming increasingly necessary to provide guidance based on scientific evidence, as so-called “evidence-based medicine” was flourishing in our speciality with the publication of numerous randomised controlled clinical trials. Therefore, the first clinical practice guideline (CPG) was launched in 1994, and the establishment of these guidelines became a leading activity of our society, with the creation of a dedicated CPG committee defining the topics and the rules for participation in the writing committees and the reviewing process. During the period from 1992 to 2015, a number of different CPGs covering key domains of cardiology were published and this became a highlight of the annual congress of the ESC. A revision process was initiated to take place every four years. Progressively, the ESC guidelines were adopted, sometimes replacing the individual national guidelines published by most of the National Cardiac Societies with ESC membership, and were translated into several languages. In order to facilitate the implementation of these guidelines, “pocket guidelines” – abridged versions summarising take-home messages – were created.

It also appeared necessary to evaluate the state of clinical practice in Europe in order to see whether recommendations were being implemented and to identify potential disparities across the different member countries. The first registry created under the umbrella of the ESC was Euroaspire, which focused on the management of cardiovascular risk factors, and then the Euro Heart Survey programme (EHS) was created, which developed a number of registries on key cardiovascular diseases, such as coronary heart disease or heart failure, with the help of National Cardiac Societies. The EHS included centralised data analysis and allowed benchmarking between participating centres and countries. This resulted in a number of important publications, but the Euro Heart Survey also faced several problems, including funding and representation, since not all National Cardiac Societies contributed.

The program was therefore redefined in 2008 and named the EURObservational Research Program (EORP) which included long-term registries and “snapshots” with successful results.

The annual scientific meeting takes the lead

The quality of the scientific content of the annual meeting, together with the expansion of international collaborations with sister societies (see below), led to a rapid growth of the audience of our conference from numbering 10,000 in the early 1990s to more than 30,000 in the 2010s, making our meeting the largest international cardiology conference in the world. The annual presentation of hotlines, including game-changing clinical trials, new clinical practice guidelines, focused sessions, and original scientific contributions became a mainstay in the panorama of international cardiology. Interestingly, the audience which was originally made up predominantly of European cardiologists included a growing number of participants from the Americas, Asia, and Africa, showing the attractiveness of ESC science for the rest of the globe, and making our annual congress a unique forum for discussions around cardiology.

Keeping all components of cardiology together

The diversification of expertise in cardiology into, e.g., arrhythmias/pacing, interventional cardiology, imaging, and heart failure, raised concern amongst the ESC leadership about the risk of fragmentation of our speciality into several highly specialised and somewhat competing entities – a process that was being observed elsewhere. After intense discussions, it was concluded that some areas needed a structure distinct from the existing working groups due to their importance, and the concept of associations was born. The principle was to create autonomous scientific structures with their own boards and scientific committees, and with two obligations: to organise an annual scientific meeting on the subject of their sub-speciality and to create their own journal about their sub-speciality. In 2003, the first associations were created: the European Heart Rhythm Association (EHRA) and the European Association of Echocardiography, later renamed the European Association of Cardiovascular Imaging (EACVI). One year later, two new associations were launched: the ESC Heart Failure Association (HFA) and the European Association for Preventive Cardiology (EAPC). Later on, this list was completed by the creation of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in 2006, the Acute Cardiovascular Care Association (ACCA) – now abbreviated “ACVC” – in 2011, and the Association of Cardiovascular Nursing and Allied Professions (ACNAP) in 2018. This organisation allowed all cardiologists, whether general or specialised, and allied professionals to be included together under the umbrella of the ESC. Presidents of the associations became members of the ESC board and therefore participated in the definition of the general policy of our society.

In parallel, several councils were created in order to give a forum to different categories of professionals such as basic researchers (Council of Basic Cardiovascular Science), hypertension specialists, or the nurse council, which also evolved into an association.

Finally, working groups, an important pillar of the European Society of Cardiology, continued to develop their scientific activities on more specific, focused topics such as adult congenital heart diseases, thrombosis, and myocardial and pericardial diseases, leading to fruitful exchanges between experts.

A network of global collaborations

Initially confined to Europe, the constitution of the ESC progressively included sister societies around the Mediterranean basin and the Caucasus, so that the original number of 14 National Cardiac Societies increased to 31 in 1992 and to 56 in 2015. All these societies contribute to shaping the ESC’s future and have voting rights for the election of the ESC Board.

It also appeared necessary to establish a framework for collaboration with important sister societies. Agreements were signed with the American College of Cardiology in 1991 and with the American Heart Association in 1992, leading to the creation of joint symposia at annual meetings organised in Europe or the United States. It became clear that the ESC needed to continue to expand its scientific collaborations with sister societies, and the concept of affiliated cardiac societies was born in 2003 with the affiliation of the Argentinian Society of Cardiology, followed by the South African Society of Cardiology, the Gulf Society of Cardiology, and the Azerbaijan Society of Cardiology. This was followed by a number of agreements that led to intensive scientific exchanges including joint sessions, discussions, and translation of guidelines in South and Central America, Canada, Asia, Australia, and Africa.

At the end of this period, 39 affiliated cardiac societies maintained regular collaborations with the ESC, and the number of non-European Fellows of the ESC became significant.

Opening of the Brussels office

Concerned by the decline in public funding of research in cardiovascular medicine, the ESC leadership contributed actively to the 5th European Union framework program for research and development.

However, the limitations of punctual interventions at the EU level were acknowledged, and it was decided to open a permanent office close to the European Commission in order to have regular contacts with decision makers and to develop advocacy for cardiovascular patients. This new office opened in 2013 and was dedicated both to advocacy and to activities related to health economics, together with the compilation of key data on cardiovascular diseases and their management across Europe, leading to the publication of the ESC Atlas. The Brussels office, located close to the European Commission building, has since considerably developed its activities, particularly for discussions on health care and medical research in Europe.

The ESC journal family

The two main journals of the ESC – the European Heart Journal, focusing on clinical science, and Cardiovascular Research, dedicated to basic science – became leading journals in their respective areas. Between 1992 and 2015, the impact factors of the European Heart Journal and Cardiovascular Research rose from 1.6 to more than 20 and from 1.5 to 5.9, respectively. The two flagship journals were completed by several sub-speciality journals, including Europace (1999), the European Journal of Heart Failure (1999), the European Journal of Echocardiography, later renamed the European Heart Journal of Cardiovascular Imaging (2000), the European Journal of Cardiovascular Nursing (2002), the European Journal of Cardiovascular Prevention and Rehabilitation (2003), the European Journal of Acute Cardiac Care (2012), the European Heart Journal of Cardiovascular Pharmacology (2015), The European Heart Journal – Quality of Care and Clinical Outcomes (2015), and the first open access journal, ESC Heart Failure (2014). Therefore, the ESC journal family offered a wide range of publications in the different areas of cardiology.

In 2015, the overall distribution was close to 26,000 for the European Heart Journal, 6,700 for Cardiovascular Research, and ranged from 4,600 to 9,000 for the sub-speciality journals.

Internal organisation: structure and changes

The rapid growth of various activities within the ESC needed to be supported by a dedicated staff. Originally, there were only 12 employees, but by 2015, the overall staff had grown to over 180. In parallel, the general coordination and the daily management of the structure were ensured by Chief Executive Officer Wil Neiman (through 1988), Alan Howard (1988-2008), Roberto Ferrari (2009, interim CEO), and then Isabel Bardinet who took over in 2009 and was still in office in 2015. It is fair to say that without the support of such a devoted and competent staff and of CEOs who shared a common vision of leadership, the ESC would not have become a leading world-class organisation in cardiology.

One important step regarding the nomination of key board members was taken when it was decided that constituent bodies, i.e., National Cardiac Societies, associations, working groups, and councils, would directly take part in the election process. Before 2008, the Nominating Committee was the structure which not only interviewed the different candidates but also made the selection of proposals (one candidate for one position), which were then adopted by the General Assembly of the ESC. There was consensus on the need to make the process more open, and the Nominating Committee was asked to propose several names for each position in order to make the process more democratic and to let our constituent bodies express their preferences. This system was put in place for the 2008 election and has provided overall satisfaction since then.

In parallel, several strategic plans defining goals to be achieved, financial governance, and changes in the composition of the ESC board – including non-voting, but important, positions such as chairpersons of the Congress Programme Committee, the Guidelines Committee, and editor-in-chief of the European Heart Journal – were undertaken in order to adapt our society to its growing complexity.

Finally, the post-2010 period was characterised by the rapid development of remote distance tools such as the ESC e-learning platform (ESCeL) and the creation of ESC congress 365 which provides free access to a wide range of presentations made at our annual congress for those who could not attend. This greater integration of technology was believed to be essential in order to fulfil the expectations of younger generations.

In conclusion, the years from 1992 to 2015 were a blooming period for our society which allowed the ESC to provide a wide array of scientific services to the cardiology community at large. The opening of the European Heart House, the creation of sub-speciality associations and of affiliated cardiac societies, the development of a dense worldwide network of collaborations, and the opening of the Brussels office are some of the most important steps which contributed to the success of our society.