This Year's ESC Meeting Had Lots of Great Trials

The Study of the Week takes Labor Day off--because I have been busy working at the ESC meeting. Here is a brief review.

Hi everyone. Happy Labor Day. I am at 36,000 feet above Spain on my way to Hamburg Germany—for a talk tomorrow at the University of Lubeck.

I went to the European Society of Cardiology meeting. As many of you know, I work as a physician journalist for theheart.org | Medscape Cardiology. My primary responsibility there is the This Week in Cardiology podcast. But I also write columns and do interviews.

Since I am traveling today to Hamburg, I will use this post to send you to some of my writings from the meeting.

First a few comments about the ESC meeting. ESC is the largest cardiology meeting in the world. The congress site in Madrid may be my favorite. The classrooms are indoors, of course, but nearly all the walking and gathering areas are outdoors. The weather here is terrific. Sun. Light wind. Dry. A full five stars.

The second to thing to say about ESC this year is the numerous important trials presented. It’s as if every important trial was held for ESC. I will tell you about three trials but there are well more than a dozen to discuss in the upcoming weeks.

My first time at ESC was in Munich in 2012. This is my 13th year attending. We had virtual-only for 2 years in the pandemic.

The third thing to say about ESC is how beautiful Europeans are. It was rare to see poorly dressed or overweight attendees. I realize this isn’t an empirical observation; I don’t have a p-value. But life just seems different here.

The fourth thing to say about ESC is that I think Spain may be underrated. Madrid is clean; there are sidewalks everywhere; the food is good, and people are nice. The language is fun.

My three picks to write about thus far

DIGIT HF

This trial randomized patients with heart failure and reduced ejection fraction to digitoxin (a slightly different form of digoxin) or placebo. The trial was positive. The primary endpoint of all-cause death or hospitalization for heart failure was reduced by a statistically significant 18%. This occurred on top of standard medical therapy of HF.

This is a huge deal, because for years, the class of digoxin-like drugs called cardiac glycosides have fallen out of favor over safety concerns. I have long felt that these safety concerns stem from highly biased observational studies wherein sicker patients get the drug.

The DIGIT HF trial puts these concerns to rest, but there are many nuances in the interpretation and translation of the results to real world practice. Provocatively, the drug cost next to nothing—a factor that may influence its use in practice.

Five Big Messages From the DIGIT-HF Trial

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REBOOT and BETAMI-DANBLOCK

ESC featured two large trials testing routine use of beta-blockers in patients who had just had myocardial infarction without substantial impairment of LVEF. REBOOT was a Spanish trial; BETAMI and DANBLOCK were merged trials from Norway and Denmark.

These were huge pragmatic outcome trials. REBOOT reported no difference in the primary outcome of death, MI, or hospitalization for heart failure. BETAMI-DANBLOCK reported a statistically significant 15% reduction in the primary endpoint of death, MI, unplanned coronary revascularization, ischemic stroke, heart failure or malignant ventricular arrhythmia.

You would think that conflicting results would make translation of this evidence quite complicated. I don’t think so. And I tell you why in this piece: Beta-Blockers Post MI: A Clear Clinical Message.

REFINE ICD

It took Canadian investigators more than a decade to finish this RCT of the primary prevention ICD (vs no ICD) in post-MI patients who had a LVEF of 35-50%. Current practice is to consider a patient eligible for an ICD only if the EF is less than 35%. We use this cut-off for 2 reasons: it was used in the seminal trials and because the risk of arrhythmic death parallels LVEF.

REFINE ICD authors enhanced the risk of patients by requiring two non-invasive measures of high arrhythmic risk. Inclusion required abnormal heart rate turbulence, measured from a simple Holter monitor, and abnormal T-wave alternans, measured from a stress ECG.

The authors did something quite smart. They kept track of patients who screened out of the study because they did not have the electrical markers. And, it turns out that having an impaired LVEF and these two electrical abnormalities led to a doubling of the risk of having cardiac arrest.

But the ICD did not lead to an improvement in the primary endpoint of all-cause mortality. I wrote about the trial and its implications: Time to Nix the Primary Prevention ICD?

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I also did three videos, which have not posted yet.

One was an interview with the Axel Diederichsen, senior author of DANCAVAS II, an RCT of cardiac screening in Denmark; the other interview was with Prash Sanders, the senior PI of the CAAN AF trial of AV node ablation vs medical rate control in patients with permanent AF who have biventricular ICDs.

I also had a video debate with David Cohen, an interventional and structural cardiologist regarding the timing of aortic valve intervention in patients with severe but asymptomatic aortic stenosis. David has been on Sensible Medicine previously.

I will be back next week with a standard Study of the Week. Thanks for your support.