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19ÈME EDITION


CARDIO ‘018 : « APPROCHE PRATIQUE DU PATIENT CARDIAQUE »

16.06.18 – @ THE HOTEL (BRUSSELS)


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One-quarter of high risk patients denied anticoagulation after AF ablation
One-quarter of high risk patients do not receive anticoagulants after ablation of atrial fibrillation (AF), according to the latest survey of European practice.The EORP Atrial Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC), reveals that 65% of patients were taking anticoagulants one year after ablation of AF.1 But up to 25% of patients at high risk of stroke (defined as a CHA2DS2-VASc score >1) were not taking any anticoagulant drug. And around half of patients with a low stroke risk (CHA2DS2-VASc score of 0) were still anticoagulated one year after the procedure.Study author Professor Josep Brugada, Hospital Clinic, University of Barcelona, said:“Our pilot study was in medium to high volume AF ablation centres and we would expect them to be following anticoagulation protocols. But often the follow-up is performed by a GP or general cardiologist at another centre. Good collaboration between the two centres is absolutely mandatory to ensure that patients received recommended treatments.”This was a prospective, observational registry of consecutive patients undergoing a first AF ablation procedure in 10 European countries. It included 1 410 patients from 72 cardiology centres with medium to high expertise (defined as performing >50 AF ablations per year). The current analysis of one-year follow-up data is published in European Heart Journal.2 It provides a contemporary picture of European AF ablation success and complication rates, and how centres assess success of the procedure.The study found that catheter ablation of AF maintained sinus rhythm in 74% of patients overall. Success without antiarrhythmic drugs was achieved in 41% of patients. When post-ablation atrial flutter/tachycardia were excluded, complications occurred in 2.5% of patients and fewer than 1% were considered major. While 90% of patients had symptoms before the ablation, 55% had no symptoms afterwards.Professor Brugada said:“In this survey of medium to high expertise centres the overall success rate of AF catheter ablation is relatively high and the overall complication rate is relatively low. The study protocol did not require discontinuation of antiarrhythmic therapy after the 3-month blanking period although it is considered good practice when there is no arrhythmia recurrence.”He added: “We found that protocols for antiarrhythmic therapy were followed more strictly in Northern Europe. Physicians did not give the medication unless the patient had a documented arrhythmia recurrence. It could be that in Southern Europe there is a tendency to give antiarrhythmic drugs if patients have symptoms, without requiring specific documentation of an arrhythmia.”Arrhythmia recurrences during the 3-month blanking period were the only predictor of failure 12 months after the procedure. Doctor Elena Arbelo, co author, also from the Hospital Clinic of Barcelona, said:“Patients who had an atrial arrhythmia during the first 3 months were more likely to have an arrhythmia after the blanking period. But an arrhythmia during the blanking period should not prompt an early re-ablation because 63% of these patients did not have a later arrhythmia. We should still wait for 3 months to assess the real result of the ablation.”

Success of the procedure was consistent across European regions. Both success and complication rates were not influenced by the number of AF ablations the centres performed each year. Professor Brugada said: “These results were not surprising because all centres in the study had medium to high expertise and 50 procedures per year is probably above the cut-off point for quality. We are currently conducting the long term registry which includes all centres and we may find different results in the low volume centres.”

The one year follow up was performed in-person for 58% of patients while 42% were followed up by telephone. In-person follow-up was more frequent in Southern and Eastern Europe. Dr Arbelo said:

The high level of telephone contact suggests that one centre performed the ablation and another conducted the follow up. It shows how different real life is from clinical studies which require intense follow up monitoring with devices to document arrhythmia recurrences and symptoms.

Professor Brugada concluded:

We found a consistently high success rate and few complications in medium to high volume centres across Europe. But inconsistent use of anticoagulants and antiarrhythmic drugs at one year shows that follow-up needs to be improved. Close cooperation between centres performing ablations and physicians doing the follow-up is essential to ensure that all patients in Europe receive appropriate treatment after the procedure.”

Study examines use of electrical energy for treating certain type of atrial fibrillation
Among patients with untreated paroxysmal (intermittent) atrial fibrillation (AF), treatment with electrical energy (radiofrequency ablation) resulted in a lower rate of abnormal atrial rhythms and episodes of AF, according to a study in the February 19 issue of JAMA.Arial fibrillation affects approximately 5 million people worldwide and is associated with an increased risk of stroke. Drug treatment is recommended by practice guidelines as a first-line therapy in patients with paroxysmal AF. « Radiofrequency ablation is an accepted therapy in patients for whom antiarrhythmic drugs have failed; however, its role as a first-line therapy needs further investigation, » according to background information in the article.Carlos A. Morillo, M.D., F.R.C.P.C., of McMaster University, Hamilton, Canada, and colleagues compared ablation to drug treatment as first-line therapy in patients with paroxysmal AF who had not previously received treatment. The trial included 127 patients at 16 centers in Europe and North America; 61 patients received antiarrhythmic drug treatment and 66 radiofrequency ablation.Recurrence of an atrial tachyarrhythmia lasting longer than 30 seconds (the primary measured outcome) occurred more often in the antiarrhythmic drug group than in the ablation group, 44 patients (72 percent) vs. 36 patients (55 percent). Asymptomatic AF was also observed more frequently with drug treatment, 11 patients (18 percent) compared with 6 patients (9 percent). Symptomatic recurrence of abnormal rhythm was more common with drug treatment, 36 patients (59 percent) in the antiarrhythmic drug group compared with 31 patients (47 percent) in the ablation group.Quality of life was improved overall by both treatments but not significantly different between groups. No deaths or strokes were reported in either group; 4 cases of cardiac tamponade (the accumulation of a large amount of fluid [usually blood] near the heart that interferes with its performance) were reported in the ablation group.The authors conclude that recurrence of an atrial tachyarrhythmia was frequent in both groups, and that when offering ablation as a therapeutic option to patients with paroxysmal AF who have not previously received antiarrhythmic drugs, the risks and benefits need to be discussed and treatment strategy individually recommended.
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Cardiovascular complications of type 2 diabetes associated with levels of physical activity
The risk of cardiovascular complications in people with type 2 diabetes is directly related to the frequency and duration of physical exercise, according to results of a large follow-up study reported today on World Diabetes Day.(1) Notably, those with low levels of physical activity had a 70% greater risk of cardiovascular death than those with higher levels.
Studies have shown indisputably that those diagnosed with type 2 diabetes are up to five times more likely to develop heart disease or stroke than healthy subjects in the general population. The risks for developing the disease have been clearly identified: age, family history and obesity, which is why the first-line treatments are a healthy diet, weight loss and regular exercise.
Studies have also consistently shown that physical activity is directly related to the risk of cardiovascular disease and mortality in all population groups. For example, a 2007 study from the National Institutes of Health in the USA found that recommendations for moderate activity (at least 30 minutes on most days of the week) or vigorous exercise (at least 20 minutes three times per week) was associated with a 27% and 32% overall decreased mortality risk, respectively.(2)
Now, on World Diabetes Day, a new follow-up study from a large Swedish cohort of subjects specifically with type 2 diabetes similarly shows that those who engage in low levels of physical activity are at a « considerably » greater risk of cardiovascular disease and death than those who exercise at higher levels.
The study is reported today in the European Journal of Preventive Cardiology.
Low level activity was defined in the study as never or once or twice a week exercise for 30 minutes, while high level activity was defined as three of more times a week. The cohort comprised a total of 15,462 subjects (6963 doing low level activity and 8499 high level) with a mean age of 60 years from the Swedish National Diabetes Register; they were followed for five years or until a first cardiovascular event or death.
Results showed that those in the low level activity group had a 25% greater risk of coronary and cardiovascular events than those in the higher activity group, and a 70% greater risk of a fatal cardiovascular event. The results were calculated as statistically significant, and were maintained when controlled for age, gender, diabetes duration, type of hypoglycaemic treatment and smoking.
Further sub-group analysis similarly found « statistically compelling » hazard estimates. For example, those with both baseline and final (five-year) low physical activity levels had considerably higher risk estimates (of 70–110%) for coronary and cardiovascular disease and mortality than all other study subjects (including those who raised their exercise levels from baseline). Thus, stepping up the duration and frequency of exercise following a diagnosis of type 2 diabetes will lower the risk of cardiovascular complications and death; remaining inactive will maximise the risk.
« Regular physical activity is an important part of the diabetes management plan and these findings underline the importance of implementing regular physical activity as part of lifestyle measures, » say the investigators.
Commenting on the results, the study’s first author Dr Björn Zethelius from the University of Uppsala in Sweden said: « The message from this study is clear. Avoid a sedentary lifestyle. Engage in physical activity. Alongside diet, these are the cornerstone of type 2 diabetes treatment. If you are presently on a low level of physical activity, do more. »
Dr Zethelius added that increased physical activity among those with type 2 diabetes has important public health implications, simply because of the increasing prevalence of the disease.
The results from the study, he said, have « high validity » because they were obtained from nationwide registers with wide coverage and real-life data from type 2 diabetes patients.

References
1. Zethelius1 B , Gudbjörnsdottir S, Eliasson B, et al. Level of physical activity associated with risk of cardiovascular diseases and mortality in patients with type-2 diabetes: report from the Swedish National Diabetes Register. Eur J Prevent Cardiol 2013; DOI: 10.1177/2047487313510893.
2. Leitzmann MF, Park Y, Blair A, et al. Physical activity recommendations and decreased risk of mortality. Arch Intern Med 2007; 167: 2453–2460.

* According to the World Diabetes Federation, the number of people with diabetes is increasing in every country. In Europe, prevalence is put at 6.7% of the total population, with more than one-third of the cases undiagnosed. In North America, prevalence has now gone beyond 10%.
*World Diabetes Day: http://www.idf.org/worlddiabetesday
* The European Journal of Cardiovascular Prevention and Rehabilitation is a journal of the European Society of Cardiology.
* More information on this press release and a PDF of the paper is available from the ESC’s press office
press@escardio.org
About the European Society of Cardiology
The European Society of Cardiology (ESC) represents 80,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

Authors:
ESC Press Office
Email: press@escardio.org

Young adults with congenital heart disease can benefit from physical activity
The diagnosis and treatments of congenital heart disease have improved so much that many babies now born with heart defects can still look forward to a long and fulfilling life. Just two generations ago, the majority of babies born with heart defects died before their first birthday, but today many of these conditions can be corrected.(1) Indeed, the population of patients with congenital heart disease who reach adulthood – and the number of adults – is now expected to grow at a rate of 5% per year. However, residual lesions may persist such that some patients may still need lifelong care.

Many in this newly emerging patient group have been heavily protected from birth and encouraged towards a sedentary non-disruptive lifestyle. In fact, one study found that only one in five children with congenital heart disease had ever been given formal advice on physical activity. Yet the truth is that exercise is as beneficial for this group as it is for any other; but which physical activities and with what frequency and intensity?

New recommendations published today by the Working Group of Grown Up Congenital Heart Disease and the Section of Sports Cardiology of the EACPR emphasise that the majority of those with congenital heart disease will achieve « significant improvement of their exercise capacity as well as their psychological state ».(2,3) The key, says the report’s first author Professor Werner Budts from the University Hospital Leuven, Belgium, is that the activity is appropriate for each individual.

« We hope that these recommendations will offer reassurance to patients and physicians alike, and encourage a physically active life style, so that patients with congenital heart disease can achieve the benefits of regular exercise at the lowest possible risk, » said Professor Budts.

The recommendations – the first ever specifically for adolescents and young adults with congenital heart disease – cover a wide range of physical exercise, from everyday activity to participation in leisure time sports, with the recommendation of individualised exercise prescription based on five hemodynamic parameters: ventricular function, pulmonary arterial pressure, aortic diameter, arrhythmia, and arterial saturation. These five parameters provide a basis for evaluation and for a tailored approach to each individual.Once these five parameters have been assessed, the programme of activity can be safely introduced with an intensity appropriate to each patient (« relative intensity »). It is for this reason, says Professor Budts, that a wide range of activities has been included in the recommendations, so that most patients with congenital heart disease can find a physically appropriate activity and can be positively encouraged. Some « high static » sports, for example, are included (such as water skiing and rowing) as are team games. Participation in team sports, in particular, are encouraged, where levels of similar physical fitness might be found.

But, warns Professor Budts, « patients should monitor their symptoms and heart rate to ensure they do not exceed the recommendations, at least for prolonged period of times, particularly for start-stop sports like football ». He adds that those who feel that their fitness is lower than that of their team-mates should be supported « to either find an alternative team or sport« .
« So the recommendations also offer physicians a decision platform to help keep patients within exercise limitations and ensure their sports are safe for them, » says Professor Budts.
« However, activity advice for those with normal hemodynamic and electrophysiological status will not differ from the general population. Only for those with residual lesions will recommendation be more restrictive. In these cases the severity of some lesions causes an additional pressure or volume load on the heart and great vessels which could become unacceptable at certain intensities. Being more (but not too) restrictive could avoid further damage.
« Yet, for the majority of young adults with congenital heart disease we believe that patient-tailored advice will improve health behavior, influence positively their cardiovascular risk profile, and ultimately benefit outcome. »

References
1. Congenital heart disease describes a range of heart defects present at birth. Such conditions include septal defects (« hole in the heart »), in- and outflow tract obstructions, great vessels stenosis, transposition of the great arteries, and univentricular hearts. Many of these defects can now be diagnosed during pregnancy with ultrasound scanning. In the majority of cases, no obvious cause is identified.
2. The Working Group of Grown Up Congenital Heart Disease and the Section of Sports Cardiology of the European Association for Cardiovascular Prevention & Rehabilitation are both communities of the European Society of Cardiology.
3. Budts W, Börjesson M, Chessa M, et al. Physical Activity in adolescents and adults with congenital heart defects; Individualized exercise prescription. Eur Heart J 2013; doi:10.1093/eurheartj/eht433

Authors:
ESC Press Office
Email: press@escardio.org

Death rates from heart disease continue to decline in most of the EU, but some countries are ‘cause for concern’
Death rates from heart disease in the European Union have more than halved in many countries since the early 1980s, according to new research published online today (Wednesday) in the European Heart Journal [1]. In the majority of countries, there have been ongoing steady reductions in heart disease death rates in both sexes and most age groups, including among younger people, despite increases in obesity and diabetes during this time. However, heart disease remains a leading cause of death in Europe.

The authors of the study say their analysis shows little evidence for the hypothesis that the reduction in deaths from coronary heart disease (CHD) might be beginning to plateau among younger people in the EU as a whole as the gains from reduced smoking rates are increasingly cancelled out by recent upward trends in obesity, diabetes and other risk factors for heart disease.

However, there was significant variation between individual countries, and evidence of a levelling off and even increases in heart disease deaths among some age groups in some countries. The absolute numbers of deaths from CHD remain high, even in countries showing encouraging downward trends in mortality.

“It is clear that there are some countries in which trends are cause for concern, where overall rates of decrease in CHD mortality do appear to have slowed, and a small number of countries in which CHD mortality rates have begun to increase significantly in recent years or decades in younger subpopulations,” said Dr Melanie Nichols, a Research Associate from the British Heart Foundation Health Promotion Research Group at the University of Oxford (UK), who is now working as a research fellow at Deakin University, Australia. “In addition, we should emphasise that cardiovascular disease remains the leading cause of death in Europe, and it is important that we continue to focus efforts on primary prevention, including reducing smoking, improving diets and physical activity levels.” [2]

Dr Nichols and her colleagues in the Oxford research group looked at trends in deaths from coronary heart disease between 1980 and 2009 in both sexes and four age groups: under 45, 45-54, 55-64, and 65 years and over.

They found that almost all EU countries had a large and significant decrease in death rates from CHD over the last three decades in both men and women when all ages were considered together. Denmark, Malta, The Netherlands, Sweden and the UK had the largest decreases in mortality for both sexes during this time. The exceptions to these significant decreases were among men in Hungary, Latvia, Lithuania and Poland, where the decreases were small and not statistically significant, and in Romania where there was a small, statistically significant increase. Among women, non-significant decreases were found in Greece, Hungary, Lithuania, Poland, Romania and Slovakia.

There was some evidence that the downward trends were beginning to plateau in those aged under 45 among men and women in Italy, Latvia, Lithuania and the UK, among men in Poland and Slovakia, and among women in the Czech Republic and France. In the 45-54 year age group, there was evidence of a possible plateau in both sexes in Latvia and the UK, and also in Lithuania among women and Sweden, Austria, the Czech Republic and Slovakia among men. In Greece, women aged 45-54 showed a constant and significant increase in death rates.

Dr Nichols, said: “Overall, across the EU, rates of death from coronary heart disease have continued to fall in most age groups in most countries. There are some exceptions, however, and there remain wide disparities across Europe in both the absolute rates of death from heart disease and the rates of improvement.

“In a small number of countries, there is some evidence that the decreasing trends may be slowing, including among younger age groups, probably due to increases in risk factors such as obesity and diabetes. These countries are, however, clearly in the minority.”

In their paper, the authors say that the increase in risk factors for coronary heart disease, such as smoking, obesity and diabetes, could still have an impact on death rates in years to come. “This effect is, however, not yet clearly apparent across the EU, and there may still be time for public health policy and action to have an impact on these risk factors . . . ,” they write. “It is crucial that future research continues to monitor trends in CHD risk factors and mortality across the EU and to examine the relationships between preventable risk factors and CHD among younger adults. Any indications of potential plateauing of CHD mortality trends among younger age groups – which were evident in this study for some countries but not yet for the EU as a whole – would be an important advance warning of potentially very high future burden of CHD as the cohort ages.”

Dr Nichols points out that their results could be affected by differences in the way countries record and code data. In addition, the researchers were unable to look at any of the reasons for differences between countries, or to draw links between these results and the possible causes within countries.

References
1. “Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980-2009”, by Melanie Nichols, Nick Townsend, Peter Scarborough and Mike Rayner. European Heart Journal. doi:10.1093/eurheartj/eht159
2. Cardiovascular disease causes over four million deaths a year in Europe and over 1.9 million in the European Union. It causes 47% of all deaths in Europe and 40% in the EU. Ref: “European Cardiovascular Disease Statistics 2012”, by Nichols M, Townsend N, Scarborough P, Luengo-Fernandez R, Leal J, Gray A, Rayner M. European Heart Network: http://www.ehnheart.org/cvd-statistics.html
3. The British Heart Foundation funds the authors’ positions at the University of Oxford. The study arises from the European Heart Health Strategy II project (EuroHeart II), which has received co-funding from the European Union, in the framework of the Health Programme. The EuroHeart II project is coordinated by the European Heart Network and the European Society of Cardiology.

Authors
The European Heart Journal is the flagship journal of the European Society of Cardiology (http://www.escardio.org). It is published on behalf of the ESC by Oxford Journals, a division of Oxford University Press.

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