Cardiology Council Research Articles

Integrated care using the ABC-stroke pathway improves cardiovascular outcomes and survival in patients with recent ischaemic stroke: a population-based cohort study

Abstract Background A recent European Society of Cardiology (ESC) Council on Stroke position paper proposed the ABC-stroke pathway, a holistic and integrated care approach to optimise the post-stroke management for patients with recent stroke, and associated heart disease. The ABC-stroke pathway is based on 3 pillars: "A" Appropriate Antithrombotic therapy; "B" Better functional and psychological status; and "C" Cardiovascular risk factors and Comorbidity optimisation (including lifestyle changes). There are limited data on the impact of adherence to the ABC-stroke pathway on post-stroke patient outcomes. Purpose We aimed to investigate the potential impact of ABC-stroke pathway adherence in the Clinical Data Analysis and Reporting System (CDARS) database in Hong Kong. Methods The analysis included patients with new-onset ischaemic stroke recorded in CDARS between 1st June 2006 and 31st May 2022. Multivariable Cox proportional hazards regression analyses were performed to evaluate the association between adherence to the ABC-stroke pathway and the primary outcome. The primary endpoint was a composite outcome of recurrent ischaemic stroke, transient ischaemic attack, haemorrhagic stroke, myocardial infarction, heart failure and all-cause death. Secondary outcomes were the individual components of the composite outcome, and cardiovascular death. Results Of the 9,669 included patients with ischaemic stroke (mean age 69.6 ± 13.4 years; 42.5% female), 58.1% were adherent to all 3 main ABC-stroke pillars. After 1 year of follow-up, adherence to the ABC-stroke pathway was associated with a lower risk of the primary composite endpoint (HR: 0.80; 95% CI: 0.72–0.88). Risk reductions increased progressively with a higher number of ABC-stroke criteria obtained (Figure 1). On multivariate analyses of the secondary outcomes, ABC-stroke pathway-adherent care was associated with a reduced risk of all-cause mortality (HR: 0.72; 95% CI: 0.62–0.85), cardiovascular death (SHR: 0.64; 95% CI: 0.45–0.90), haemorrhagic stroke (SHR: 0.50; 95% CI: 0.38–0.67) and heart failure (SHR: 0.771; 95% CI: 0.596-0.998) (Table 1). Conclusion In a large cohort of patients with ischaemic stroke, adherence to the ABC-stroke pathway was associated with a reduction of the risk of adverse outcomes.

Adherence to an integrated care pathway for stroke is associated with lower risk of major cardiovascular events: A report from the Athens Stroke Registry

BackgroundA recent European Society of Cardiology (ESC) Council on Stroke position paper proposed a holistic integrated care management approach for stroke patients, to improve cardiovascular outcomes. The impact of implementing the ABCstroke pathway ‘concept’ on clinical outcomes has never been estimated before. In order to investigate the potential effect of ABCstroke pathway adherence to cardiovascular outcomes post stroke, we performed a post-hoc analysis from the Athens Stroke Registry. Methods and resultsThis analysis was performed in the Athens Stroke Registry, which includes all consecutive patients with acute first-ever ischemic stroke. The Kaplan–Meier product limit was used to estimate the cumulative hazard of each outcome according to adherence with the ABCstroke pathway.We studied 2513 patients [median (IQR) age 71 (62–78) years; 37.7 % female] with ischemic stroke with median follow-up period of 30 (6–75) months. Full adherence to the ABC pathway was identified in 156 (6.2 %) of the patients, while 192 (7.6 %) did not adhere to any of the therapeutic pillars of ABCstroke. Full adherence to ABC treatment pathway was associated with significant reduction of stroke recurrence, compared to patients with no or partial adherence (aHR: 0.61; 95 %CI: 0.37–0.99), as well as a lower risk of MACE (HR: 0.59; 0.39–0.88) and death (aHR: 0.22; 95 %CI: 0.12–0.41). ConclusionFull adherence to the ABCstroke pathway based on the current guidelines was evident in only 6.2 % of our ischaemic stroke cohort but was independently associated with lower risks of stroke recurrence, major cardiovascular events and mortality. This highlights a potential opportunity to improve clinical outcomes post-stroke with a holistic or integrated care management approach.

An Integrated Perspective for Understanding the Psychosocial Impact of Acute Cardiovascular Events

The psychosocial impact of acute cardiovascular disease (CVD) events, including cardiac and stroke events, is gaining increasing recognition, with recommendations regarding an integrated cardiovascular approach coming from organizations such as the European Society of Cardiology Council on Stroke. This study aims to document the similarities and differences between heart disease and stroke in the prevalence, predictors and consequences of, and treatments for, anxiety and depression. This scoping review provides an overview of the evidence of similarity and difference in the mental health impacts of cardiac events and strokes. It found that research into postevent anxiety and depression is generally more advanced in the cardiac area than in the stroke area, with research related to poststroke anxiety prevalence, predictors, and treatment being particularly sparse. Despite these limitations, the review reveals enough similarities in the psychosocial impacts of cardiac and stroke events to warrant investigation of the potential for integrated psychosocial services for CVD patients, paying particular attention to collaborative care models of intervention.

Position statement for the development of adult congenital heart disease units in Latin America and the Caribbean: Recommendations by the adult congenital heart disease chapter and pediatric cardiology council of the interamerican society of cardiology …

In 2020, there was an estimated prevalence of more than 1.8 million adults with congenital heart disease (ACHDs) living in South America, and 677,000 in Central America and the Caribbean. The ACHD mortality is higher in developing countries, compared with developed countries, and it has been shown that concentrating this population in specialized ACHD units improves their survival and prognosis. Currently, Latin American (LATAM) and Caribbean countries have an insufficient number of specialists and specialized ACHD units. Analyzing this situation, the Inter-American Society of Cardiology's (IASC) ACHD chapter and Pediatric Cardiology Council have prepared the first recommendations for developing ACHD units in LATAM and Caribbean countries. This article is the first collaborative work between South American, Central American and Caribbean countries. It describes the main points for organizing and developing ACHD units adapted to our own reality. Each point has been discussed in terms of barriers and challenges, followed by specific recommendations for improving and developing ACHD care. They have been reviewed and endorsed by the International Society for Adult Congenital Heart Disease (ISACHD), and the goal of their implementation is for each ACHD unit in the region to have the standards of quality and efficiency to improve the prognosis and survival of ACHDs in the region.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

European survey on valvular heart disease clinical experience from the European Society of Cardiology council on valvular heart disease.

AimsThe aim of this survey is to analyze how current recommendations on valvular heart disease (VHD) management have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field.Methods and resultsA total of 33 questions, distributed via email to all European Society of Cardiology (ESC) affiliated countries through the newsletter of the ESC council on VHD, were answered by 689 respondents, mainly from tertiary care settings. The results of this survey showed that VHD patients are mostly managed by tertiary care centres, where multi-disciplinary heart teams are frequently a reality. Cardiac computed tomography (CT) is often used in the preprocedural planning of transcatheter interventions, particularly for sizing and deliverability assessment. Echocardiography represents the most widely used imaging modality in the diagnostic, intra-operative and follow-up phase of VHD patients. Cardiac magnetic resonance (CMR) is still largely underused, also for conditions such as mitral annular disjunction, or for the assessment of left ventricle volumes where it is considered as the gold standard, despite 3D volumes by echocardiography having proved good comparability with CMR. As for endocarditis, despite still underused, transesophageal echocardiography (TEE) represents the approach of choice for the diagnosis of native and prosthesis valve endocarditis (up to 46% of the respondents use it). In this context, positron emission tomography-CT is largely underused.ConclusionThere is widespread adoption of current recommendation on the evaluation of VHD and these are frequently used to guide patient management. Nonetheless, there are still many discrepancies across centres and countries which need to be addressed with the aim of improving patients’ management and outcomes and ultimately positively impacting on healthcare resources.

Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: A: Appropriate Antithrombotic therapy.B: Better functional and psychological status.C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

Interpretation and actionability of genetic variants in cardiomyopathies: a position statement from the European Society of Cardiology Council on cardiovascular genomics.

This document describes the contribution of clinical criteria to the interpretation of genetic variants using heritable Mendelian cardiomyopathies as an example. The aim is to assist cardiologists in defining the clinical contribution to a genetic diagnosis and the interpretation of molecular genetic reports. The identification of a genetic variant of unknown or uncertain significance is a limitation of genetic testing, but current guidelines for the interpretation of genetic variants include essential contributions from clinical family screening that can establish a de novo assignment of the variant or its segregation with the phenotype in the family. A partnership between clinicians and patients helps to solve major uncertainties and provides reliable and clinically actionable information.

The year in basic vascular biology research: from mechanoreceptors and neutrophil extracellular traps to smartphone data and omics.

2020 has been an extraordinary year. The emergence of COVID-19 has driven urgent research in pulmonary and cardiovascular science and other fields. It has also shaped the way that we work with many experimental laboratories shutting down for several months, while bioinformatics approaches and other large data projects have gained prominence. Despite these setbacks, vascular biology research is stronger than ever. On behalf of the European Society of Cardiology Council for Basic Cardiovascular Science (ESC CBCS), here we review some of the vascular biology research highlights for 2020. This review is not exhaustive and there are many outstanding vascular biology publications that we were unable to cite due to page limits. Notwithstanding this, we have provided a snapshot of vascular biology research excellence in 2020 and identify topics that are in the ascendency and likely to gain prominence in coming years.

Interdisciplinary management of acute ischaemic stroke - current evidence on training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention: A step forward.

Stroke, a vascular disease of the brain, is the #1 cause of disability and a major cause of death worldwide. Stroke has a major negative impact on the life of stroke-affected individuals, their families and the society. A significant proportion of stroke victims indicate that would have preferred death over their after-stroke quality of life. Mechanical thrombectomy (MT), opening the occluded artery using mechanical aspiration or a thrombus-entrapment device, is a guideline-mandated (class I, level of evidence A) treatment modality in patients with large vessel occlusion stroke. MT clinical benefit magnitude indicates that a universal access to this treatment strategy should be the standard of care. Today there is a substantial geographic variation in MT deliverability, with large-scale disparities in MT implementation. In many countries effective access to MT remains severely limited. In addition, many of the MT-treated patients are treated too late for a good functional outcome because of logistic delays that include transportations to remotely located, scarce, comprehensive stroke centres. Position Paper from the European Society of Cardiology Council on Stroke and European Association for Percutaneous Cardiovascular Interventions on interdisciplinary management of acute ischaemic stroke, developed with the support of the European Board of Neurointervention fills an important gap in systematically enabling interventional cardiologists to support stroke intervention in the geographic areas of unmet needs in particular. We review strengths and weaknesses of the document, and suggest directions for the next steps that are swiftly needed to deliver MT to stroke patients more effectively.

The interpretation of CHA2DS2-VASc score components in clinical practice: a joint survey by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, the EHRA Young Electrophysiologists, the Association of Cardiovascular Nursing and Allied Professionals, and the European Society of Cardiology Council on Stroke.

This European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals, and European Society of Cardiology (ESC) Council on Stroke joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the 'C' component, as well as the 'one-off high reading of blood pressure' to score on the 'H' component. Greater confidence was expressed in scoring the 'H' component (72.3%) compared with the 'C' (46.2%) and 'V' (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%). The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the 'C', 'H', and 'V' elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications. The preferred referencing resources to calculate the score varied among different healthcare professionals. Guideline education to healthcare professionals and updated and unified online/mobile scoring tools are suggested to improve the accuracy in scoring the CHA2DS2-VASc score.

Association for European Paediatric and Congenital Cardiology recommendations for basic training in paediatric and congenital cardiology 2020.

The recommendations of the Association for European Paediatric and Congenital Cardiology for basic training in paediatric and congenital cardiology required to be recognised as a paediatric cardiologist by the Association for European Paediatric and Congenital Cardiology are described below. Those wishing to achieve more advanced training in particular areas of paediatric cardiology should consult the training recommendations of the different Association for European Paediatric and Congenital Cardiology Working Groups available on the Association for European Paediatric and Congenital Cardiology website (www.aepc.org) and the respective publications 1-6. The development of training requirements is the responsibility of the Educational Committee and the Association for European Paediatric and Congenital Cardiology Council in collaboration with the Working Groups of the Association for European Paediatric and Congenital Cardiology. Trainees should be exposed to all aspects of general paediatric and congenital cardiology from fetal life to adolescence and adulthood. Centres performing generalised and specialised work in paediatric and congenital cardiology should be committed to deliver postgraduate training. At each training institute, trainers should be appointed to supervise and act as mentors to the trainees. Association for European Paediatric and Congenital Cardiology will provide basic teaching courses to supplement the training process.

Use of Renin-Angiotensin System Antagonists in Patients with Hypertension and COVID-19 Infection: A Rapid Review and Meta-analysis

KEY FINDINGSAmong patients with confirmed COVID-19 infection and hypertension, there is insufficient evidence that RASantagonists are associated with mortality or severe COVID-19 disease.• There is uncertainty with regards to the safe use of renin-angiotensin system (RAS) antagonists, such asangiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), for COVID-19 patientswith hypertension and other comorbidities (heart failure, chronic kidney disease) because of two possiblecontradictory mechanisms 1) upregulation of ACE2 receptors that may facilitate the virus entry into the lung.and 2) control of unabated angiotensin II levels reducing acute lung injury.• Based on very low-quality retrospective cohort studies, there is insufficient evidence that RAS antagonists areassociated with increased mortality (6 studies) or severe disease (10 studies) among patients with confirmedCOVID-19 infection and hypertension.• There are 36 ongoing studies (21 RCTs, 1 single-arm trial, 4 prospective cohorts, 4 retrospective cohorts, 4 casecontrol, and 2 cross-sectional) on this topic.• The European Society of Cardiology (ESC) Council on Hypertension, the International Society of Hypertension(ISH) and the joint statement by the American College of Cardiology (ACC), American Heart Association (AHA),and Heart Failure Society of America (HFSA) all caution against discontinuing RAS-related treatments inpatients with hypertension who become infected with COVID-19.

Corrigendum to: Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke and Low quality of some generic cardiovascular medicinal products represents a matter for growing concern.

Corrigendum to: Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke and Low quality of some generic cardiovascular medicinal products represents a matter for growing concern.

Hypertension, renin–angiotensin–aldosterone system inhibition, and COVID-19

Hypertension, renin–angiotensin–aldosterone system inhibition, and COVID-19

Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke.

Oral anticoagulation in patients presenting with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1 (CHA2DS2-VASc of 2 in women) remains a challenging approach in clinical practice. Therapeutic decisions need to balance the individual benefit of reducing thromboembolic risk against the potential harm due to an increase in bleeding risk in this intermediate risk patient population. Within the current opinion statement of the European Society of Cardiology working group of cardiovascular pharmacotherapy and the European Society of Cardiology council on stroke the currently available evidence on the anti-thrombotic management in patients presenting with a CHA2DS2-VASc of 1 is summarized. Easily applicable tools for a personalized refinement of the individual thromboembolic risk in patients with atrial fibrillation and a CHA2DS2-VASc score of 1 that guide clinicians through the question whether to anticoagulate or not are provided.

P2717Differences between european society of cardiology and european resuscitation council criteria for diagnosis of STEMI - Do they translate into differences in patient management or outcome?

P2717Differences between european society of cardiology and european resuscitation council criteria for diagnosis of STEMI - Do they translate into differences in patient management or outcome?

European Society of Cardiology Council for Cardiology Practice worldwide survey of transcatheter aortic valve implantation beliefs and practices.

Background Transcatheter aortic valve implantation (TAVI) continues to gain popularity in the management of patients with severe aortic stenosis (SAS). Distribution of resources to maximise appropriate use remains a priority. Design & methods To determine the current perceptions and behaviours regarding SAS patient management, an 18-point multiple-choice questionnaire was distributed to European Society of Cardiology (ESC) Council for Cardiology Practice (CCP) e-journal and/or electronic newsletter subscribers. Respondents to all questions were considered. Sub-analyses based on respondent age, practice setting and geographical location were performed. Results Of 1245 full respondents, 41.5% were aged ≥ 51 years, 22.7% were aged 41-50 years and 35.8% were aged ≤ 40 years. The majority were located in Europe (77.5%), followed by Asia/Oceania (11.6%), America (7.6%) and Africa (3.4%). In-hospital and out-of-hospital cardiologists accounted for 57.4% of and 28.5% of the sample, respectively, with the remainder being general practitioners/other. The majority of respondents (70.1%) claimed to diagnose between one and five cases of SAS per month. Free access to TAVI was reported by 41.2%, being less common for those aged ≤ 40 years (32.7%; p < 0.001), those located in Asia/Oceania, America and Africa (20.1%, 18.1% and 2.4%, respectively; p < 0.01 in each case) and in-hospital compared to out-of-hospital cardiologists (35.7% vs. 54.5%, respectively; p < 0.001). The most common reason for not referring a patient for an aortic valve intervention was assessment that the patient was high risk/non-operable (55.5%), followed by short life expectancy (30.5%). The most common reason for referring a patient for TAVI over surgical replacement was surgical risk score (56.9%). The most commonly perceived main complication of TAVI was stroke (28.9%), while the most frequently selected main benefit was improvement in quality of life (37.2%). A high proportion (82.5%) of respondents believed that TAVI is/may become a viable option for lower-risk SAS patients in future. Conclusion The population of potential TAVI is significant worldwide, with key barriers to referral being access limitations and poor physician education. Strategies to minimise these factors are paramount.

Cardiovascular Research Onlife talks with Dr Leonardo Sacconi, 2017 Outstanding Investigator award of the European Society of Cardiology council for Basic Cardiovascular Sciences.

Cardiovascular Research Onlife talks with Dr Leonardo Sacconi, 2017 Outstanding Investigator award of the European Society of Cardiology council for Basic Cardiovascular Sciences.

Dr Jyoti Patel talks with Dr Oliver Söhnlein, 2017 outstanding investigator award of the European Society of Cardiology council for basic cardiovascular sciences.

Dr Jyoti Patel talks with Dr Oliver Söhnlein, 2017 outstanding investigator award of the European Society of Cardiology council for basic cardiovascular sciences.