CardioBrief

Europace 2009 is taking place right now in Berlin. Here are some of the interesting noncommercial press releases from the European Society of Cardiology coming out of the meeting:

• Implanted Defibrillators: New Recommendations for Drivers with ICDs
• Atrial fibrillation in endurance athletes still poses problems for sports cardiologists
• “Big disparities in the treatment of arrhythmias across Europe”

Here are the press releases:

Implanted Defibrillators: New Recommendations for Drivers with ICDs

Patients with an Implantable Cardioverter Defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions are imposed making these recommendations an important guideline for patients.

A consensus statement with recommendations for drivers with ICD’s was presented at a press conference at the Europace 2009 meeting, in Berlin, Germany on Sunday 21 June.

A team of twelve experts from the European Heart Rhythm Association (EHRA), the Council on Cardiovascular Nursing and Allied Professions in ESC (CCNAP) and the Section Cardiac Rehabilitation of the European Association of Cardiovascular Prevention and Rehabilitation, reviewed the literature, assessed the risk and issued a consensus statement.

“Driving restrictions vary across different countries in Europe. We hope the document may serve as an instrument for European and National regulatory authorities to formulate uniform driving regulations”, explained Johan Vijgen, chairperson of the task force*.

“Driving restrictions are perceived as difficult for patients and their family and have an immediate consequence for their lifestyle. In addition to the psychological and societal impact, the driving ban may also pose a considerable impact on employment and education and thereby economic status”, said Vijgen.

The document presents recommendations for private driving (group 1) and professional driving (group 2). Definitions of the European Council Directives (80/1263/EEC) and (91/439/EEC) are used.
-Group 1: drivers of ordinary motor cycles, cars, and other small vehicles with or without a trailer.
-Group 2: drivers of vehicles over 3.5 metric tonnes or passenger carrying vehicles exceeding eight seats excluding the driver.

Since the introduction of the ICD in the early 1980s, multiple trials have demonstrated the efficacy of ICDs for the prevention of sudden arrhythmic death. This resulted in a significant increase in the number of implants. In Western Europe alone, 63000 ICDs were implanted in 2006 and 85500 ICDs in 2008.

Many patients are currently implanted for primary prevention (treatment of patients at risk for life-threatening arrhythmias who have never had sustained ventricular arrhythmias). The risk for sudden incapacitation is lower in these patients. Therefore, driving restriction should be less strict for these patients, than for patients implanted for secondary prevention (those who have survived a life-threatening arrhythmia).

“Patients and their families should receive adequate discharge education and standardized information on driving recommendations. This should result in a better adherence to the recommendations. It should be emphasized that the risk is mainly a consequence of the underlying condition and not of the presence of the ICD”, explained Prof Vijgen.

The consensus statement will be published in the June issue of Europace, the official journal of the European Heart Rhythm Association.

*Members of the task force include Johan Vijgen (chairperson) Belgium, Gianluca Botto (Italy) , John Camm (United Kingdom), Carl-Johan Hoijer (Sweden), Werner Jung (Germany), Jean-Yves Le Heuzey (France), Andrzej Lubinski (Poland), Tone M. Norekvål (Norway), Maurizio Santomauro (Italy), Martin Schalij (The Netherlands), Jean-Paul Schmid (Switzerland), and Panos Vardas (Greece)

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Atrial fibrillation in endurance athletes still poses problems for sports cardiologists

New research efforts to prevent and treat arrhythmias associated with endurance sports

The fulfilment which so many people increasingly derive from competitive sports and endurance training comes with a real – even if rare – twist. Because, while most people will enjoy the benefits and pleasures of exercise, there are a few for whom regular athletic training will increase the risk of cardiac arrhythmias and even sudden death, especially among those in middle-age or with pre-existing cardiac diseases.

“It’s for this reason that sports medicine has focused on pre-participation screening,” says Dr Luis Mont from the Hospital Clínic de Barcelona, Spain, “in an attempt to detect any hidden heart disease.” On the other hand, disturbances in heart rhythm, particularly atrial fibrillation, which represent one of the major cardiovascular reasons for hospital admission, is more common among cyclists, marathon runners and other athletes with a long history of endurance training.

Dr Mont reports that atrial fibrillation is more frequent in middle-aged individuals who formerly took part in competitive sports and continue to be active, or simply in those involved in regular endurance training without having actually participated in competitive sports. “So we have to look at the effects of endurance or athletic training with a more open view,” says Dr Mont.

However, he adds that the cost-effectiveness of routine pre-participation screening in a broad population of athletes and endurance sports participants has not yet been clarified. A debate on the subject takes place at this Congress on Sunday 21st June at 16.00.

What does seem clearer, however, is that long-term endurance sport participation may well increase the incidence of cardiac arrhythmias, particularly atrial fibrillation, atrial flutter, sinus node dysfunction, and right ventricular premature beats. “Given the fact that an increasing number of individuals engage in regular endurance sports,” says Dr Mont, “it is certainly of great interest to define which recommendations for sport should be implemented in an individual patient, and how best to manage arrhythmias in participants.” Atrial fibrillation is the most common arrhythmic condition, and sudden cardiac death remains a risk.

Three papers presented at this congress by Dr Mont’s group reflect the research effort now being directed towards sports cardiology and the prevention and treatment of rhythm disorders.

1. Efficacy of the circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. CPVA is a recently introduced technique which identifies the signals causing the atrial fibrillation and isolates their source in the pulmonary veins from the left ventricle of the heart. The technique has been successfully used in routine patients with atrial fibrillation and, according to new data presented here in Berlin, is now as effective in AF secondary to endurance sports as in other causes. A series of 182 patients in Dr Mont’s Barcelona clinic found that freedom of arrhythmias following CPVA was similar in the sports participants as in the regular patients. Left atrial size and long-standing atrial fibrillation were the only independent predictors for arrhythmia recurrence after the treatment, not sports participation.

2. Deconditioning reverses expression of cardiac fibrosis markers in an animal model of endurance training. A more basic science study from Dr Mont’s group in Barcelona also suggests that those with a history of arrhythmias following endurance training may benefit from a period of “deconditioning” following their efforts. The suggestion follows a study in animal models which found that markers of cardiac fibrosis in rats whose treadmill exercise was followed by a period of inactivity returned to control levels. Endurance exercise causes cardiac structural changes, including atrial and right ventricular fibrosis – and this fibrosis may play a role in the development of arrhythmias. Although it has been noted that the athlete’s heart regresses after inactivity it is not known if the sport-induced atrial and right ventricular fibrosis also reverses after deconditioning. This study suggests that it does and that a period of inactivity might be of benefit in those with a history of fibrillation.

3. Losartan attenuates heart fibrosis induced by chronic endurance training in an animal model. Just as inactivity after training may inhibit cardiac fibrosis in animal models, a similar study suggests that the anti-hypertensive drug losartan prevents the heart fibrosis induced by endurance exercise. The anti-fibrotic effect of losartan, an angiotensin type-II receptor antagonist, appears to be mediated suppression of angiotensin II-induced proliferation of fibroblasts. Again, markers of fibrosis were reduced by administration of losartan.

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“Big disparities in the treatment of arrhythmias across Europe”

• • Latest statistics on pacemakers and implantable cardiac devices presented at Europace 2009
  • Germany has one of the highest ICD implant rates in Europe
  • EHRA commits to reducing inequalities

The latest statistics regarding the use of pacemakers and implantable cardiac devices in Europe was presented on Sunday 21 June, at EUROPACE 2009, the meeting of the European Heart Rhythm Association (EHRA)1 which takes place in Berlin, Germany from 21 to 24 June.

These facts and figures, including the current status of healthcare systems across the continent, were included in the EHRA White Book2.

“This document is intended to be the starting point in a move towards a homogeneous way of looking at data, resources, physicians, etc., across Europe. Comparison among the countries belonging to the European Society of Cardiology (ESC)3, should help to standardise health resources by promoting knowledge of the status and bringing it to the attention of all public authorities” explained Christian Wolpert, Chairman of the National Societies who contributed the information gathered in the White Book.

“One of the roles of a European Association like the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), is to promote equal access to therapy for all patients across Europe. To do so, the first step is to compile data on the current situation in various ESC membership countries, compare them, and propose actions to move towards harmonization. The current leadership of EHRA agreed on the importance of obtaining as much current information as possible concerning the situation of the practice of electrophysiology in Europe” stressed Wolpert.

Under the leadership of Professors Christian Wolpert from Germany, Panos Vardas from Greece and Josep Brugada from Spain, a group worked to collect the most recent figures. To ensure up to date data, Presidents of the different Working Groups and National Societies were contacted and asked not only to provide data, but also to verify and authorize all the information that became available through various sources.

Wolpert declared that this data is also the point of comparison for the future: “ By knowing where we are today, we will be able to benchmark in the future and see how diverse countries evolve. This means that this book must be an ongoing process, with updated information, new and additional data, and the inclusion of information from those countries that have not yet been able to collect and transmit their records.”

Explaining the data, Prof Wolpert highlighted certain trends, such as the fact that “more and more, cardiologists represent the majority of implanters while surgeons are decreasingly active in these procedures.”

There is a disparate coverage of diseases and treatments within the European Union and the European Society of Cardiology member countries outside of the EU. Some of the countries have no reimbursement e.g. for ICD or pacemaker therapy and the penetration of catheter ablation of atrial fibrillation is very different.

Data shows big differences across ESC member countries in:

• • Guideline implementation.
• • The number of trained physicians and specialised centres
• • The number of implantations which seems to depend not only on reimbursement and financial resources, but also to be a function of the number of centres and physicians dedicated to electrophysiology and implantation of devices.
• • The numbers of ICD implanting centres range from less than 1 to 6.87 per million citizens.
• • Pacemaker therapy is performed in the range of 88 to a maximum of around 1200/ million inhabitants.
• • ICD implant rates including CRT-D devices range from approx. 2.5 to 354 per million inhabitants. The data shows an increase for a subset of 16 western and northern European countries around 15% from 2006 to 2007.
• • Regarding a potentially different medical consensus in specific countries the use of biventricular pacemakers vs. biventricular ICDs shows a 8:1 ratio at the highest down to 1:1.2 ratio as the lowest.
• • In the field of invasive electrophysiology and catheter ablation for supraventricular and ventricular arrhythmias the number of centres available is variable ranging from less than 0.2 to more than 3 centres/ million. The total number of catheter ablations is increasing and reaches a maximum of more than 200/ million in approx. half of the countries. However, there is a strong discrepancy comparing all 35 countries, displaying a wide range from less than 20 to more than 450/ million.
• • The same is true for catheter ablation of atrial fibrillation which varies tremendously, linked to reimbursement policies but also to different approaches in the various EP societies.

“As an example, Germany, hosting the EUROPACE meeting this year, has one of the highest implant rates for ICD’s in Europe with a total of 1037 centres which implant pacemakers; 200 centres implanting CRT resynchronisation devices and a total of 360 ICD implanting institutions” highlights Prof Wolpert.

“Within the Non-EU ESC member countries, there has been a steady increase of therapy availability and disease coverage, however, there are still many countries that struggle with reimbursement, trained personnel and technical support, which requires a strong effort and leaves much space for improvement. It is the task and the intention of EHRA to support any initiative to improve steadily the situation for these countries in order to reduce the disparities”.

The first EHRA White Book was published in 2008 containing information for 2006 and 2007 from 35 of the 51 ESC member countries from all sites of Europe and parts of the Middle East. The book was made fully available to the public in an electronic version and within short time it became one of the most popular downloads in the EHRA website.

“We hope that this book will be useful to all electrophysiologists and health care providers in Europe and will initiate an era of evolution towards a more unified Europe in terms of equal access to therapy for all patients, regardless of their country origin”, concluded Prof Wolpert.

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