Expos & Conferences

 The ESC Congress 2011, Paris

Innovations in Cardiology

The team at Middle East Health never cease to be amazed by new technology and the speed at which it is developed. We attended the European Society of Cardiology (ESC) Congress in Paris in August at the invitation of Philips Healthcare, where this rapid progression in technology, specifically new cardiologyrelated tech, was much in evidence.

Four years ago we spoke to one of the key researchers, Jürgen Weese, behind Philips’ heart modelling initiative. At that stage it was very much a work in progress. Today, Philips is marketing a number of products that use this research. This is like caffeinefuelled progress to develop such sophisticated stuff in such as short space of time. And the ultimate beneficiaries... cardiac patients, who are unfortunately a distressingly large segment of modern society.

At the ESC Congress we spoke again to Weese, a research fellow at Philips Research Laboratories in Hamburg, Germany, about the heart modelling programme used in Philips’ EP Navigator and the company’s Heart Navigator. Both tools are used by clinicians in cardiac intervention. They are essentially a new class of medical product that make cardiac intervention more efficient as well as simplifying the extraction of complex cardiology data.

“They are new tools. There has been nothing like this before. They are enabling new things in cardiology,” Weese noted. Using a generic model describing the heart’s shape, variability and appearance as a starting point, it is then possible to match this up against 3D images of the patient’s own heart to produce a digital, patient-specific heart model which can used in diagnosis and intervention.

Initially, Weese explained, these models were developed using CT data for the cardiac anatomy extracted from CT images. However, he said it was now possible to create patient specific models using other imaging modalities such as MR and rotational x-ray.

“In the past four years we have made refinements to the detail, to make it more accurate. And we have also made the software more robust,” Weese said. “If you use such tech in the field there are many challenges to make the user satisfied – simply, you must be able to press a button and it should work.”

Philips EP Navigator was launched in 2007. It was developed to help clinicians treating patients with atrial fibrillation, one of the most common forms of abnormal heart rhythm. Selected patients with atrial fibrillation may be eligible for treatment by catheter ablation. These catheters are used to deliver a burst of radio-frequency energy that destroys the tissue causing the abnormal rhythm disorder. The Philips EP Navigator generates a patient-specific heart model from a 3D CT image or an intra-procedural 3D atriography which, when combined with live fluoroscopy data from a cath lab system, shows the position of the catheters being used, as well as the detailed atrial anatomy in real time on a single image. This information is designed to support the electrophysiologist in performing such complex EP procedures.

The Philips Heart Navigator similarly allows clinicians to match a 3D image of the cardiac anatomy with a live fluoroscopy image to show the position of catheters and devices, such as a heart valve, in real time, providing live image guidance during minimally invasive cardiovascular procedures. During planning, the software suggests the best projection for the procedure and provides virtual device templates so that the most appropriate device size can be selected. This ability to accurately plan for and then guide highly complex cardiac interventions, has the potential to significantly improve cardiac care and patient outcome

Weese explained that there are two key ways how a patient-specific heart model benefits the physician. One is to automate and make assessment much more efficient and faster and second, to automatically provide a variety of functional information – such as heart chamber volumes.

“For diagnosis in CT, for example, it improves the workflow and reduces the time that the doctor has to spend to get the result.

“There are many things that the technology does that take place behind the scenes. For example, it automates generation of standard cardiac views, which previously had to be done by reformatting the data manually.

“Also, for example, the coronary tree extraction is presented automatically,” Weese added.

“Functional assessment is also supported – so you can get the chamber volumes, which is automatically generated from the segmentation. It also measures the diameter of vessels like the aorta automatically.”


He said research was still ongoing. “There is still much potential for heart modelling – such as that to do with septal defects and mitral valves, for example. I think we will be making further steps in this area in the future.

“We have also had requests for more detail and more complex models of the heart – and this is what we are working on.”

And although the focus currently is on cardiology, he said they have had requests to adapt this technology to other parts of the body, such as the brain. Clearly there is massive scope for this technology going forward. We wait with anticipation to see what Philips produces next.

Record breaking event

There was a lot going on at the ESC Congress in Paris. The congress is an annual event held in a different European city each year and although the focus is largely on the presentation of the latest cardiology-related scientific papers, the product exhibition floor was surprisingly large and active.

Professor Michael Böhm, chairman of the ESC Congress Programme Committee, was jubilant. “The ESC Congress 2011 in Paris has been a record breaking event,” he commented. “With a total attendance of 32,946 participants, this is our largest congress ever. We are especially pleased to see that more and more delegates are coming from outside Europe. Large delegations came from Brazil, Japan, China and India this year.

Speaking to journalists at the congress, Joris van den Hurk, Vice President and General Manager Cardiology Care Cycle, Philips Healthcare, made clear the necessity for innovation in cardiology, highlighting some frightening statistics.

“Cardiology is a hot topic,” he said, “because cardiac disease is the world’s biggest killer.

“More than 30% of people will die from cardiac disease.

“In the US 40-50% of healthcare budgets are spent on cardiovascular disease,” he noted.

However, he stressed that it is a global killer. “In emerging markets, such as China and India, it is growing faster than in other part of the world.

It is estimated that 20 million people will die from CVD by 2015 – and yet a significant number of these deaths can be prevented if people make the right lifestyle choices.


Commenting about the importance of the ESC Congress, Prof Böhm said that the quality of the scientific content at the ESC Congress attracts more and more participants each year.

“The medical community was eagerly waiting to hear about the results of important trials such as ARISTOTLE, Dal- VESSEL AND RUBY-1 which were announced in Paris,” he said. (See the web link at the end of this article for further details from the congress.)

ARISTOTLE was probably the highlight of this congress as apixaban was shown to be superior to warfarin in the prevention of stroke and systemic embolism in patients with atrial fibrillation. The drug was also associated with less bleeding and lower mortality rates.

Further interesting studies were the PRODIGY trial, which showed that a 6 months dual antiplatelet therapy after stent implantation (drug eluting and bare metal, stable and unstable patients) was as effective as 24 months, and associated with statistically lower bleeding hazards. The EXAMINATION trial, which demonstrated equivalence for a drug eluting stent (everolimus eluting) vs. bare metal stents (cobalt chromium) with respect to hard clinical endpoints but lower stent thrombosis and revascularization rates up to 1 year, was also a highlight of this year’s congress.

New clinical guidelines were also released by the European Society of Cardiology on the management of cardiovascular disease in pregnancy.

“Because of the increasing prevalence of heart disease in young women, these guidelines emphasising the need for screening and risk assessment of pregnant women are extremely important,” said Professor Michel Komajda, President of the European Society of Cardiology. Other guidelines announced by the ESC include new recommendations on peripheral artery diseases and updated ESC guidelines on the management of non-ST elevation acute coronary syndromes.

Prof Komajda highlighted the fact that 2011 is the year of the registry. “Registries allow us to see if doctors are following guidelines. The PURE registry, for example showed worrying results: patients with previous cardiovascular disease are not receiving adequate treatment. The registry which enrolled 154,000 adults in 17 countries, found that in low income countries, 80% of cardiac patients received no medication at all, while in high income countries 11% did not receive adequate treatment. There is still progress to make in prevention and treatment all over the world.”

Next year’s congress in Munich, Germany, from 25-29 August, will put the spotlight on the theme: “From bench to practice”.

An App for sleep apnea

On the exhibition floor Philips Healthcare launched of a number of new products that they say will “transform detection, diagnosis and treatment” in cardiology.

The company showed off their new – and the world’s first – sleep apnea mobile app designed specifically for cardiologists to aid early detection and diagnosis of sleep apnea amongst their patients. Called ‘Sleep & Cardio’, the app for iPhone and available in Apple’s App Store – is designed to expand cardiologists’ knowledge of sleep apnea and CVD, providing simple suggested steps for identifying patients who are at risk, a summary of existing guidelines and access to the latest clinical information and training.

Other new products from Philips included a range of devices such as the ‘HeartStart FR3’ for professional emergency responders. Philips says it is the smallest and lightest professional-grade automated external defibrillator (AED) among leading global manufacturers.

The Xper Flex Cardio Physiomonitoring System is designed for use in the cath lab. According to Philips the system ushers in a new era of hemodynamic assessment, offering seamless integration of Fractional Flow Reserve (FFR) measurement and the power of 16-lead ECGs to interventional environments, alongside patented ST Mapping and Culprit Artery Detection.

For the management and treatment of sleep apnea, which is particularly prevalent in CVD patients, the company released the ‘BiPAP autoSV Advanced System One’, a new servo-ventilation device that treats patients with sleep apnea and also provides improved real-time access to data, including compliance and efficacy, to help clinicians assess future treatment.

IntelliVue MX40

Also at the ESC Congress in Paris, Philips showed off their recently launched wearable patient monitor – the IntelliVue MX40. The monitor is designed for the monitoring of ambulatory patients and during patient transport. It is cleverly designed to resist the buildup of bacteria on the device and is completely waterproof enabling patients to shower and move freely around the hospital while constantly being monitored.

The MX40 combines the benefits of the acclaimed IntelliVue X2 and Philips telemetry into a single, compact wearable monitor.

The monitor will help clinicians to better manage patient alerts. The MX40 provides continuous monitoring over large distances in the hospital, with access to the IntelliVue Smarthopping Network. A colour touch-screen display on the device presents the patient’s name as well as easily accessible vital information such as ECG, SpO2 and non-invasive blood pressure.

A spokesperson for Philips explained that the IntelliVue Information Center is an integral part of the MX40 solution, providing real-time surveillance, reporting, data storage and interfacing with the hospital’s electronic medical record system.

The MX40 is designed with cleaning and infection prevention in mind, featuring a unique patient cable connector that resists the build-up of dirt and liquid. The device is smooth, allowing easy wiping. The case material supports cleaning by many disinfectants.


What do patients receiving optimal medical therapy after a heart attack die from?

Because of improved management at the acute stage, the risk of dying in hospital after a heart attack has decreased by about 50% in the past 10 years. Likewise, the prescription of recommended medications when patients leave hospital, has resulted in improved survival and fewer recurrent heart attacks. One of the challenges is now to try and further decrease long-term mortality in patients who leave the hospital on "optimal" medical therapy (i.e. who are prescribed all the recommended medications).

The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) is a nationwide survey of patients hospitalised for acute myocardial infarction in France at the end of 2005, during a one-month period. Patients included will be followed for a period of 10 years after the initial heart attack. At three years, fewer than 5% of the patients have been lost to follow-up.

Of a population of 3,670 patients included in the registry, 3,262 survived the initial hospitalization and had a complete prescription at discharge available. Among them, 1586 (49%) received optimal treatment (OMT).

Three-year survival was 88% in optimally treated patients, compared with 77.5% in those who did not receive all recommended medications. After taking into account the initial profile of the patients and the severity of the heart attack, there was an 18% reduction in the risk of dying in patients receiving optimal medical therapy.

Analysis of the factors related with 3-year mortality in patients who received optimal treatment showed that the risk of death was related to older age (> 75 years), severity of the cardiac disease (larger infarction, more extensive disease of the coronary artery), associated conditions, such as diabetes mellitus, stroke, cancer or persistent smoking; in contrast, patients who had had a coronary angiogram during the initial hospitalization had a markedly reduced risk of dying.

These findings suggest that there is still room for improvement in patients who receive the best possible medical treatment; of these patients, 12% still die during the 3 years that follow the initial heart attack.

A broader use of coronary angiography and myocardial revascularization during the initial hospitalisation is likely to have a favorable influence on long-term outcomes. In addition, additional efforts are needed and should concentrate on better management of larger infarctions to prevent and treat heart failure, and on associated conditions such as diabetes. Persistent smoking should also be fought relentlessly.

Author: Professor Danchin, Nicolas (Paris, France)

Cardiac Disease: Coronary or not?

Acute myocardial Infarction (AMI) is a major cause of death and disability. Worldwide, one in eight patients die of an ischemic heart disease. Its rapid and accurate diagnosis is critical for the initiation of effective evidence based medical management, including early revascularization, but is still an unmet clinical need. The gradual implementation of high-sensitive cardiac troponins (hs-cTnT) in clinical practice has helped clinicians to detect and treat patients with acute myocardial infarction earlier than with conventional assays. But, high-sensitive assays have also caused considerable confusion among clinicians as to the interpretation of, in particular, minor elevations. Now, many patients with cardiovascular disorders such as tachyarrhythmia, hypertensive urgency or heart failure are also “troponin positive” with the high-sensitive assays, in the absence of a coronary obstruction. The findings emerged from the ongoing, international multicenter study APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation). Comprehensive characteristics of 887 patients, who had all presented to the emergency department with acute chest pain, were analysed. The investigators of this study focused on the clinically most challenging differential diagnosis in acute chest pain patients: AMI vs. cardiac, non-coronary diseases. They found out that by applying a simple algorithm, using presence of ST-elevation in the electrocardiogram, presentation values and changes of hs-cTnT in the first hour accurately distinguishes the two groups. Absolute changes of hs-cTnT were much more discriminatory than relative changes. Remarkably, absolute changes of hs-cTnT as low as 0.005 mcg/l had the best discriminatory power in the differential diagnosis of AMI and cardiac, noncoronary diseases. 98.4% of all patients with AMI had either presentation values above 0.028 mcg/l or absolute changes of more than 0.005 mcg/l in the first hour.

Interestingly, considering changes of hs-cTnT after the first hour, does not seem to generate much further benefit.

The high diagnostic accuracy of the combined use of hs-cTnT at presentation and at one hour, added up to an area under the curve of 0.94. In times of scarce resources, efficient allocation of invasive diagnostics will become more and more decisive in clinical practice. Patients presenting with acute chest pain are very different as to age and comorbidities and thus, their individual attitude regarding health and medical diagnostics in general. The level of pre-test probability necessary for further invasive diagnostic procedures – such as a coronary angiography – varies greatly between patients, but also physicians and was incorporated in a decision curve analysis.

The investigators showed that, again, the combined use of presentation values of hs-cTnT and its early change in the first hour was most helpful in order to properly allocate further invasive diagnostics to patients with acute chest pain and simultaneously leading to a substantial reduction in avoidable early coronary angiographies.

To sum it up, optimal troponin thresholds for hs-cTnT for therapeutic decision making – both at baseline and thereafter – remain a subject of debate. The application of the investigator’s algorithm may lead to earlier therapeutic decisions, shortening time of uncertainty for patients, more efficient use of financial resources and a substantial reduction in avoidable early coronary angiographies.

Author: Dr Philip Haaf, Department of Cardiology, University Hospital Basel

Scientific Resources from ESC 2011 http://tinyurl.com/5ulzkvq

ate of upload: 15th Nov 2011


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