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VOLUME 10 NUMBER 2 • JUNE 2013
CONFERENCE REPORT
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Cardiology & Diabetes At The Limits 2013
AJ Dalby, jl aalbers
Friday 22
nd
– Monday 25
th
March
The 15
th
At The Limits conference was held in Cape Town under
the auspices of the Hatter Institute and organised and chaired by
Prof Derek Yellon of University College London and Prof Lionel
Opie of the University of Cape Town. The meeting was sponsored
by AstraZeneca, Bayer HealthCare, Boehringer Ingelheim, Bristol-
Myers Squibb, Discovery Health, Medtronic, Novo Nordisk, Roche,
Servier, Takeda and The Coca-Cola Company.
Friday evening:
Early programming of diabetes and cardiovascular disease –
an update
Alan Lucas, Institute of Child Health, University College London
Lucas discussed programming during foetal development and
the effect of diet in post-natal period, specifically comparing
breast milk vs. formula feeding. Although better foetal growth is
associated with better cognitive function, accelerating the growth
of small infants in the post-natal period to “catch up” is associated
with increases in BP, obesity and risk of CVD. It may therefore be
necessary to avoid encouraging weight gain by overfeeding smaller
babies.
Expressed breast milk does not represent the composition of
suckled breast milk which changes during a feed and, in the longer-
term, with the time that breast feeding continues. Recognition of
this has led to the reformulation of infant feeds.
Saturday:
The Lancet Lecture:
The renin-angiotensin-aldosterone system: have we reached
the limits?
Marc Pfeffer, Brigham & Women’s Hospital, Boston, USA
Marc Pfeffer told of how he had gone to extraordinary academic
lengths over many years to undertake and publish over 100 studies
dealing with the RAAS system to show that in the end the more
extensive studied drugs were the cheaper ACE inhibitors. The more
modern ARBs now also have strong supporting data. Overall, both
ACE-i and ARBs give a 20% reduction in mortality in vascular
disease. The ARBs have specific data for ACE-intolerant patients and
for post-infarct heart failure. Combining ACE-i and ARBs has not
on the whole given improvements except in one heart failure study
by Pfeffer. He also pointed out that spironolactone and eplerenone
were very similar, and that studies (including one by his group) were
under way to evaluate whether spironolactone provides the same
benefits in heart failure as the now well established but much more
costly eplerenone.
To obtain funding for this study, Pfeffer had to gain US
government support via NIH. The direct renin inhibitors failed to
give any further benefit. “So we are at the limit of blocking the
RAAS system, we have tried to inhibit more, with no benefit”, Dr
Pfeffer concluded.
Transcatheter aortic valve implantation (TAVI) surgery –
where are the limits?
Axel Linke, University of Leipzig, Germany
In inoperable patients, TAVI, using Medtronic Core Valve
self-expanding prostheses, offers resolution of severe aortic
stenosis, but with complications of stroke (2.9%) major vascular
complications (10%) and major bleeding events (10%). TAVI has
proved better than balloon valvuloplasty, and also superior to drug
therapy in inoperable patients. The future includes valves that are
repositionable, retrievable and steerable; attempts are also being
made to reduce strokes by using filters to capture calcific debris and
to design valves that reduce aortic regurgitation.
What is the future of cardiac intervention – have we reached
the limits?
Stephan Windeker, Bern University Hospital, Switzerland
In the COURAGE trial PCI which resulted in a reduction in ischaemia
was associatedwith an improvement in longer-termoutcome. FAME
II showed marked benefit of PCI guided by FFR compared to medical
therapy, the endpoint being driven by urgent revascularisation. The
ISCHEMIA trial is in progress which may clarify the best approach
to treatment.
The comparison of PCI to CABG in SYNTAX showed that risk
stratification yielded different results in the different categories. Newer
DES may influence future outcomes. Though PCI and CABG seem to
offer similar benefits in left main coronary artery (LMCA) stenosis,
difficulties remain in choosing the best treatment for patients with
multivessel disease. The EXCEL trial is evaluating LMCA PCI vs. CABG.
Effective STEMI treatment requires improvements in the
management network.
Bioabsorbable stents may result in positive remodelling of the
coronary vessel.
The duration of dual antiplatelet therapy (DAPT) remains an
open question. One trial is in progress which will compare standard
DAPT to ticagrelor given with only one month of aspirin.
Heart failure – where are the new targets?
Martin Cowie, The Royal Brompton Hospital, London
There has been a progressive improvement in heart failure survival
over the past 2 decades with a currently low rate of mortality in
societies able to provide modern treatment. Treatment can be
improved by attending to the delivery of care. Triple therapy with
ACE-i, beta-blocker and MRA are standard in HeF-REF. Ivabradine
has an important role in reducing hospitalisation and improving
QoL.
New agents being investigated are serelaxin which improves
symptoms in AHF with 48 hours of treatment but has no effect
on readmission rates. Mortality at 6 months may be reduced.
Ultrafiltration is not beneficial with more adverse effects. (Bart,
NEJM, 2012). Other areas of research are the effects of mechanical
circulatory support, autonomic modulation with vagal stimulation
or renal denervation, the influence of sleep disordered breathing
and cardiac myosin activators, ryanodine receptor stabilisers and
SERCA2a gene transfection of the myocardium (CUPID 2a).
This is a personal South African view of the meeting. The full talks and slides are accessible
on the Lancet website, so interested CVJA readers can select any talks they would like to
see and hear.
