Euro Heart Survey and the Cardiology Challenges for the Next Decade

Prof Bernard Prendergast

Disclosures

August 30, 2018

Prof Prendergast: Welcome to Medscape UK at the ESC Congress here in Munich in Germany.

My name is Professor Bernard Prendergast. I work at St Thomas Hospital in London and I've had a lifelong interest in the field of valvular heart disease, which is the spotlight theme of this year's Congress, drawing participants from all around the world.

Medscape UK: What did we learn from the Euro Heart Survey? 

Prof Prendergast: A principal focus at this year's meeting has been the Euro Heart Survey[1] on valvular heart disease which has provided very important and updated contemporary information regarding the epidemiology and the management of valvular heart disease in 2017-2018. 

This is a snapshot survey, effectively an audit you might call it, of contemporary practice across the spectrum of Europe and encompassing data from over 7000 patients in all quarters of the continent.

And this survey attempted to address changes in practice and changes in the clinical profiles of patients in Europe with heart valve disease in comparison with a previous similar study, which was undertaken many years ago in 2001. And in doing so, it recognised that there have been major changes in the field of valvular heart disease in that period. 

Firstly, there have been two successive updates of the European guidelines regarding the management of valvular heart disease. Secondly, recognising that the explosion of transcatheter treatments for heart valve disease has clearly impacted on practice, and alongside that there has been a change in philosophy encompassing the importance of the heart team in deriving the best management approach for individual patients. 

And in a series of presentations from this survey in the last 2 or 3 days we've heard from the lead investigators with some key findings. 

Firstly, amongst the 7500 patients enrolled three-quarters have native heart valve disease, whereas 25% had undergone some form of intervention. 

The key messages were that the age of patients is increasing very, very rapidly, and degenerative heart valve disease is now much, much more common than rheumatic disease had been in the past.

Secondly, we can see the impact of the transcatheter therapies, particularly in aortic stenosis where TAVI is now almost on equal par with surgical intervention. And reflecting that fact is the finding that the majority of patients with the aortic stenosis are now very elderly, arbitrarily defined as greater than 80 years.

The other important message that came across was the adherence to guidelines was actually remarkably good across the continent. Approximately 80% of patients with aortic valve disease were being managed according to guideline recommendations. 

Unfortunately, in the field of mitral valve disease that wasn't so positive, and there is still a worrying trend of many, many patients being referred late in the natural history of their disease, for consideration of surgery or transcatheter treatments. 

So many positive messages and still many areas for improvement. 

Medscape UK: That was looking back up to where we are now. The title of one of your sessions was challenges in valve disease in the next decade. What are those challenges? 

Prof Prendergast: So we face many challenges in the field of heart valve disease in the era to come. The first will be one of logistics because we recognise that as a function of the ageing population, the number of patients with heart valve disease presenting to our care is going to increase very, very rapidly. 

And data from our own study in Oxford, the OxValve[2] study has projected that the number of patients with heart valve disease is going to double by 2046, within 20 or 25 years. And clearly this is going to be a major challenge not only for specialists in the field, but also for clinicians at large in terms of the timely diagnosis of these patients, and the very prompt referral for specialist care.

We also shouldn't overlook the fact, sitting as we are here in Europe, that worldwide, rheumatic fever is still a very major healthcare burden in less privileged and less financially advantaged countries. And as we accelerate with expensive, sophisticated technologies, with transcatheter treatments and novel imaging strategies, we need to remember that the simple basics of healthcare, the access to sanitation, access to antibiotics in streptococcal sore throat for example, will be equally important in improving the lives of many hundreds of thousands of patients around the world. 

In terms of developed healthcare, we can reflect on many, many areas of progress in the last decade that lay a very solid platform for the future. 

Transcatheter treatment for aortic stenosis is now an established modality, and it seems very likely that in a very short space of time, even within the next 3 to 4 years, we will have the data which demonstrate that TAVI is equivalent to surgery, even in low-risk patients. And that of course, presents a challenge to conventional surgery because the transcatheter approach is much more attractive to patients. And ultimately we need to acknowledge our patients' preferences and our patients’ wishes when we are choosing the appropriate treatment strategy. 

Alongside that there will be a need to answer the question regarding the durability of transcatheter valves. And again, data are now accumulating year on year in large numbers of patients demonstrating the transcatheter valves are durable at 5, 6, 7 and many more years beyond in small numbers of patients. And it's only a matter of time until we accumulate data in much larger cohorts to support the use of transcatheter valves and younger and younger patients. 

Beyond the aortic valve we will be hearing results at this Congress relating to the Mitra France [Mitra.fr] [3] study. The first randomised control trial examining the use of the edge to edge repair Mitral Clip procedure in patients with functional mitral regurgitation randomised against medical therapy. The results of that trial aren't available at the time of this recording, but they will certainly signal the pathway ahead for this emerging partner to aortic valve intervention in the mitral, and subsequently in the tricuspid space. 

And then looking beyond that we will need to work out the logistics of our departments [to] ensure that we are able to deliver the demand that the ageing population and this burgeoning field of transcatheter intervention is going to impose upon our services. 

Medscape UK: Is there still a value to a big conference like this in the internet age when we can look at things online? 

Prof Prendergast: So the ESC Congress is currently attracting over 30,000 participants to Munich to come together for educational sessions, from networking and interaction, and to hear the latest data and discussion from experts in the fields. 

Of course, you can hear a PowerPoint presentation through your own laptop in the comfort of your own home. And I think there is a need for the medical community to address the value, the added value, of attending a congress such as this in person.

And it's very evident walking around the Congress that the organisers have taken great efforts to ensure that as many of the sessions as possible are interactive in a very informal, relaxed fashion, allowing participants to interact with faculty, with immediate feedback after the sessions regarding the impact on daily practice and allowing therefore, a unique experience which wouldn't be accessible in a virtual transmission. 

The other thing that you can't escape as well is the ability to network with your peers, and there is as much energy and activity outside the lecture halls in terms of people meeting to discuss research protocols, to discuss the variations in clinical practice across the continents, and of course, the opportunity to meet up with old friends, which is a very important function alongside the academic endeavours.

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