Expos & Conferences
The ESC Congress 2011,
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
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
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
“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
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
for innovation in cardiology, highlighting
some frightening statistics.
“Cardiology is a hot topic,” he said,
“because cardiac disease is the world’s
“More than 30% of people will die from
“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
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
“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
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
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
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
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.
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
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
of recommended medications when patients leave hospital, has resulted in
improved survival and fewer recurrent heart attacks. One of the challenges is
try and further decrease long-term mortality in patients who leave the hospital
"optimal" medical therapy (i.e. who are prescribed all the recommended
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
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
hospitalization and had a complete prescription at discharge available. Among
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
was an 18% reduction in the risk of dying in patients receiving optimal medical
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
severity of the cardiac disease (larger infarction, more extensive disease of
artery), associated conditions, such as diabetes mellitus, stroke, cancer or
persistent smoking; in contrast, patients who had had a coronary angiogram
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
3 years that follow the initial heart attack.
A broader use of coronary angiography and myocardial revascularization during
initial hospitalisation is likely to have a favorable influence on long-term
In addition, additional efforts are needed and should concentrate on better
of larger infarctions to prevent and treat heart failure, and on associated
such as diabetes. Persistent smoking should also be fought relentlessly.
Author: Professor Danchin, Nicolas (Paris, France)
Cardiac Disease: Coronary or
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
diagnosis is critical for the initiation of effective evidence based medical
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
infarction earlier than with conventional assays. But, high-sensitive assays
caused considerable confusion among clinicians as to the interpretation of, in
minor elevations. Now, many patients with cardiovascular disorders such as
tachyarrhythmia, hypertensive urgency or heart failure are also “troponin
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
pain patients: AMI vs. cardiac, non-coronary diseases. They found out that by
applying a simple algorithm, using presence of ST-elevation in the
presentation values and changes of hs-cTnT in the first hour accurately
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
the best discriminatory power in the differential diagnosis of AMI and cardiac,
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
Interestingly, considering changes of hs-cTnT after the first hour, does not
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
efficient allocation of invasive diagnostics will become more and more decisive
clinical practice. Patients presenting with acute chest pain are very different
as to age
and comorbidities and thus, their individual attitude regarding health and
diagnostics in general. The level of pre-test probability necessary for further
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
allocate further invasive diagnostics to patients with acute chest pain and
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
of the investigator’s algorithm may lead to earlier therapeutic decisions,
time of uncertainty for patients, more efficient use of financial resources and
substantial reduction in avoidable early coronary angiographies.
Author: Dr Philip Haaf, Department of Cardiology, University Hospital Basel
Scientific Resources from ESC 2011
of upload: 15th Nov 2011