Key takeaways from ESC Congress 2023

He said the Hot Line late-breaking session 4 included four studies that will likely have help increase the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in the cath lab when performing percutaneous coronary intervention (PCI). These included ILUMIEN IV, OCTIVUS, OCTOBER, and an OCT vs. IVUS vs. angiography use meta-analysis. 

“These trials showed doing more imaging-guided PCI in patients with complex lesions is actually helps with a better result. This can be with IVUS or OCT. And for the first time, we have been able to show clearly there is also a clinical benefit,” Kristensen said.

   • OCTOBER showed clinical benefit for the use of OCT-adjunct imaging. 

   • ILUMIEN IV showed that OCT was linked to fewer instances of stent thrombosis. However, the study fell just short of reaching its primary endpoint, which included event-free survival from major adverse events and primary patency at 12 months. 

   • OCTIVUS showed both IVUS and OCT were non-inferior to angiography guided PCI, and the intravascular imaging cohorts had lower than expected event rates. 

   • A meta-analysis of 20 randomized trial using IVUS or OCT versus angiography imaging alone in 12,428 patients with chronic and acute coronary syndromes showed overall improved outcomes. The meta-analysis focused on endpoints such as target lesion failure, cardiac death, target vessel myocardial infarction, target lesion revascularization and stent thrombosis. Intravascular imaging resulted in reductions in the primary composite outcome of target lesion failure by 31% compared with angiography guidance. In secondary outcomes, intravascular imaging resulted in reductions in cardiac death by 46%, target vessel myocardial infarction by 20%, target lesion revascularization by 29%, and stent thrombosis by 52% compared with angiography guidance of PCI. There were also statistically significant reductions in all-cause death, myocardial infarction and target vessel revascularization with intravascular imaging guidance of PCI. The outcomes were similar for OCT-guided PCI and IVUS-guided PCI when compared individually against angiography and when compared to each other.

The meta-analysis was presented by Gregg Stone, MD, a professor of cardiology and population health sciences and policy at the Icahn School of Medicine at Mount Sinai, New York. He said this is the first study to show a clear survival benefit by using adjunct imaging in PCI. Stone said the data may help push IVUS and OCT use to higher levels of recommended use in the guidelines.

“I think we will start to use intravascular imaging more, in particular in Europe where the penetration of using this in procedures has not been high. I think in our own department, we will go home and use it a bit more. I would not say we should use it in every patient because it is expensive, but in more complex lesions, we would get some help from the imaging,” Kristensen explained. 

In Europe, cath labs use OCT or IVUS only in about 10-15% of cases, but it depends on how each country reimburses these procedures. In the U.S., use of intravascular imaging is about 20% of PCI cases. The highest rate of intravascular imaging is in Japan, where utilization is closer to 80%. Overall, Kristensen and presenters in the trials, including Stone, said these studies will help add evidence that intravascular imaging should be used to improve outcomes. 

“I think some of the older guys like me have asked if this is really necessary because it takes more time and is costly. But after these trials I am convinced we should use it more,” Kristensen said.

Complete revascularization vs. culprit lesion only strategy in older patients

Another key trial was FIRE, which looked at fractional flow reserve (FFR) physiology-guided complete revascularization vs. treating the culprit lesion only strategy for PCI in older patients with myocardial infarction. Kristensen said the study of 1,445 patients helps answer the long-standing question of which interventional strategy is best in older patients. The majority of patients in this trial were over the age of 75. 

“This trial showed that going for complete revascularization in these older patients is a good idea,” Kristensen explained. 

He said the study showed use of FFR pressure wires or angiography derived QFR measurements can be used to determine if other lesions beyond the culprit lesion causing a heart attack should be stented. 

“This has always been a debate, but this is reinforcing that we should be doing this, and doing it in the elderly population,” Kristensen said.

Semaglutide for obesity is beneficial for the heart

The drug semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, is used for chronic weight management and to treat type 2 diabetes. It also has been found to reduce the risk of major cardiovascular events such as heart attack and stroke. 

The STEP-HFpEF trial found once-weekly semaglutide also improves heart failure-related symptoms and physical function and results in greater weight loss compared with placebo in patients with heart failure with preserved ejection fraction (HFpEF) and obesity.

Kristensen said there was a lot of discussion among attendees about the results of the trial. 

ECMO does not perform well in cardiogenic shock 

Another late-breaking study presented at ESC that gained a lot of attention was ECLS-SHOCK. This used extracorporeal membrane oxygenation (ECMO) to treat patients in cardiogenic shock. This trial, similar to other previous European trials, showed ECMO was ineffective. 

“This is bad news because we have a struggle in treating these patients,” Kristensen said. 

It might be patient selection for ECMO in cardiogenic shock should be much more narrowed, he said. But added overall in Europe, there are cost vs. benefit concerns about using expensive and technically involved equipment for treating patients unless there is a clear benefit. 

In the U.S., Impella percutaneous heart pumps are often used in cariogenic shock patients. In Europe, Kristensen said there is a need for more evidence for Impella use in these patients, partly due to the higher cost of the device. He said the Danish-German DanGer study is looking at Impella use for cardiogenic shock and it should offer the data needed for better survival within the next several months.

ESC updates 5 guidelines 

Kristensen said there also were five updated sets of ESC guidelines released at the 2023 Congress. He said the biggest takeaway was in the new heart failure guidelines, which reinforce that cardiologists should be using the newer drugs now on the market as frontline therapies. 

Other guideline updates included acute coronary syndromes (ACS), endocarditis, diabetes, and a new guideline on cardiomyopathy.  

ESC sees return to normalcy following COVID

Kristensen noted that he saw ESC Congress 2023 as a return to normalcy after three years of the COVID-19 pandemic forcing cancellations of meetings, driving people to virtual meetings and requiring facemasks, vaccination records and other pandemic protocols. This year, he said, the meeting looked like a pre-pandemic meeting for the first time in four years. 

“This lively atmosphere cannot be created, frankly, with a web-based approach,” Kristensen said. “You have to have this sort of personal interaction, and I think we have succeeded in getting that at this year’s meeting.”

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