Over one thousand delegates attended this year’s Heart Rhythm Congress (HRC) in Birmingham. This report highlights some of the key elements of the meeting from the perspective of Dr Andy Hogarth (Pictured) a first time delegate and trainee in electrophysiology and devices.
The opening day marked the start of three daily sessions dedicated to the Heart Rhythm UK (HRUK) certificate of accreditation course, providing a valuable resource to physiologists, arrhythmia nurses and registrars preparing to undertake this increasingly recognised exam. HRUK have worked hard to set up a coordinated training programme which was also evident throughout the meeting with the broad range of relevant sessions directed at trainees in devices and electrophysiology. In such a rapidly expanding field a unified and coordinated training programme is essential, and it was reassuring to see firsthand the time and effort that is being put into achieving this.
The opening day was also Patient’s Day, with meetings arranged by the Arrhythmia Alliance (AA), the Atrial Fibrillation Association (AFA), Syncope Trust And Reflex anoxic Seizures (STARS) as well as the Patient’s Day Exhibition. One striking feature of this meeting was the rapport between clinicians in primary, secondary and tertiary care as well as physiologists and nurse specialists; this approach seemed appreciated by the patient groups represented.
Atrial Fibrillation remains a major cause of stroke, morbidity and mortality, and featured heavily at the congress. There have been some impressive advances in both interventions to reduce symptoms and to reduce the risk of stroke. However, the lack of awareness of AF within the population and of the interventions available to clinicians, delays the implementation of these advances. The AF Symposium looked at some of the developments in understanding and the challenges in inducing change in practice. This provided a valuable forum for clinicians and allied professionals from primary, secondary and tertiary care to discuss relevant issues, with many sessions specifically directed toward the challenges of arrhythmia management in primary care. This was particularly evident in the interesting debate surrounding screening for atrial fibrillation, how and where best to do it and the subsequent cost benefit issues.
Much time was also given over to the important issue of anticoagulation for thrombo-embolic prophylaxis and stroke risk reduction in atrial fibrillation. This was topical in light of the RE-LY trial data presented at the ESC in Barcelona earlier this year, demonstrating the oral anticoagulant dabigatran as a viable and effective alternative to warfarin, with less bleeding risk and reduced need for regular blood monitoring, potentially changing the paradigm of stroke prophylaxis for AF. Though for the time being, one message was loud and clear; the need to increase warfarin prescribing in at risk groups, particularly in the primary care setting. Strategies were outlined as to how this may be achieved, including altering the Quality Outcomes Framework to be more specific with regard to the mode of thromboembolic prophylaxis. The identification of those individuals at risk of stroke and therefore needing full anticoagulation was thus the topic of much discussion. The expert consensus seemed to be that all but those in the very lowest group of stroke risk should be considered to need warfarin, and refining and lowering of the threshold of currently used risk scores (e.g. CHADS-2) will be necessary to achieve this aim. With this in mind, it was refreshing to see the data on bleeding risk presented in a balanced manner, specifically with regard to the elderly population, in whom the risk is often over estimated. It was clear that there is a big problem with under utilisation of effective thrombo-embolic prophylaxis, with an estimated 46% of at risk AF patients not on warfarin, potentially resulting in an unnecessary 1250 strokes per year. It waits to be seen whether the next few years will see an improvement in this situation, perhaps catalysed by the emergence of effective potentially safer alternatives to warfarin.
These considerations inevitably led into discussions regarding the next revision of NICE guidance for AF management, led by experts already involved in this challenging task. Inevitably this moved the spotlight toward the issue of medical therapy for atrial fibrillation, with dronedarone being the obvious focus. As an alternative to amiodarone it has many well documented attractions, being better tolerated with a far more user friendly pharmacokinetic profile and outcome data demonstrating a decrease in cardiovascular mortality and hospitalization when compared to amiodarone (ATHENA trial). However, as an antiarrhythmic agent, it is not as effective as amiodarone. Time will tell if this last point will be of importance, as it seems likely to take the place of amiodarone in the algorithm as the first line antiarrythmic of choice for atrial fibrillation.
There was ample opportunity for the experts to discuss the efficacy and evolving techniques of catheter ablation therapy for atrial fibrillation. Increasing experience and continual developments in technology have resulted in quicker and equally effective interventional options. This evolution has already reduced procedure times down to less than 90 minutes for certain cases, whilst still maintaining efficacy. These advances are of great interest given the massive burden of atrial fibrillation on the NHS (approximately 1% of total budget) and the potential benefits from offering a potentially curative, or at least markedly alleviating, procedure to so many people.
State of the art indications and management of devices also featured prominently. There was much discussion about the indications for complex devices, and how current practice and NICE guidance are often at odds. In general, we do not implant enough devices, including basic bradycardia devices. At one end of the spectrum, the need for general education in pacing indications was again elegantly highlighted by Dr. Janet McComb’s ECG pacing indications quiz (Freeman Hospital, Newcastle) during a symposium organised in association with the Primary Care Cardiovascular Society (PCCS). Previously this quiz had been used to demonstrate the wide variety of understanding of the indications for bradycardic pacing, both in the general physicians and the cardiology specialist, from junior team member through specialist trainee to consultant. Although cardiologists had generally performed well, the results presented suggested there was continual room for improvement! This session provided an opportunity to collect answers from the delegates present and these intriguing results may be available in the British Journal of Cardiology in the near future. At the other end of the scale, it was of interest to witness well attended sessions dedicated to overcoming the hurdles of commissioning and providing a service to meet the increased demand for complex, expensive devices, including the debateable role of a device champion. As inevitably the population of people with devices grows so too will the need for lead and device extraction. Evolving techniques with tips and tricks for percutaneous removal were discussed in detail alongside surgical options, with revealing insights from Dr. Charles Byrd (Fort Lauderdale, Florida), a world leader and pioneer of lead extraction. It was refreshing to see a number of surgical colleagues contributing to other areas of the congress, in particular surgical options for atrial fibrillation, a field of apparently renewed interest.
MRI compatible pacemaker systems, as yet not routinely commercially available, had a high profile at the impressive industry exhibition. Until recently the presence of a pacemaker would have meant all other imaging modalities would had to have been exhausted, with MRI only being utilised as the absolute last resort. New leads and devices have been shown to be MRI compatible, with no damage to the function of the device or lead, following MRI scanning. However certain implant, follow-up and scan criteria need to be met, and for the time being the manufacturers describe the system as MRI conditional as oppose to MRI safe. With some specialist modifications of scanning technique it is therefore possible to MRI any part of the body, including the heart. The aging population with devices will no doubt be increasingly likely to require MRI imaging in the future, and this is an interesting field of development. Implantable Cardiac Defibrillators (ICDs) due to their nature are larger with more potential to develop electromagnetic problems, and the consequences of damage to sensing and function are potentially more serious, so for the time being ICDs remain an absolute contraindication to MRI. However, research is growing utilising specialised techniques of MRI scanning, and this, allied to the potential of MR compatible leads, may mean that MRI is even an option for certain patients with ICDs within the next 2-3 years. This field is being closely monitored with registry data.
The meeting provided an opportunity for specialists to consider various techniques for treating other challenging arrhythmias. Case study presentations and round table discussions, as well as key note addresses from world renowned experts, provided an interesting and informative forum for discussion. One particular highlight was the evolving field of catheter ablation for ventricular tachycardia (VT). Dr. Vivek Reddy, Director of the Cardiac Arrhythmia Service at Mount Sinai Medical Center New York, hosted a lively debate outlining strategies for dealing with these difficult arrhythmias. One model proposed was the provision of VT ablation for all patients with a secondary prevention indication for ICD (previous significant VT) which was backed up with promising results in terms of subsequently reduced ICD therapies. Dr. Reddy and Dr. Riccardo Cappato (Chief of Arrhythmia and Electrophysiology, Policlinico San Donato, Milan) also provided expert opinion on the field of complex atrial arrhythmia ablation. As well as fast emerging advances in atrial fibrillation catheter ablation, it seems that the face of electrophysiological intervention is changing at a rapid rate, providing cause for optimism that these challenging, intrusive and sometimes life threatening arrhythmias may be cured.
As was expected the HRC meeting 2009 provided a welcome opportunity to catch up with colleagues in what is a relatively small field (this author has never witnessed so many individuals checking their pulse for atrial fibrillation by the last morning). The annual Gala Dinner provided a focal point to the vigorous social side of the meeting, with the annual awards ceremony following a typically impressive and engaging address from Professor AJ Camm. The awards for services to arrhythmia management were as follows:
Winner – Julie Fear
Winner- Dr. Anna Maria Choy
- Miss Cath Owen
- Dr. Pascal McKeown
Winner – Miss Adele Graham
Highly Commended –Dr. Du Xin
Winner – Professor Arthur Wilde Cardiogenetic Department Academic Medical Centre, Amsterdam
Highly Commended – Specialist nurse team Imperial College
To cover all events in this article would be impossible. Other areas not discussed in detail here included interesting updates on inherited cardiac disease and sudden cardiac death in the young. This emotive and difficult field was covered by some of the UK’s leading experts with real world practical discussions about cardiac genetics, how to deal with screening and family issues, and how to approach the sudden unexplained death of a young person. Paediatric cardiac electrophysiology was also represented. In addition, there were enlightening and engaging discussions on syncope, along with various models of how to set up and run an effective syncope service. Finally, there was the thriving contribution from delegates with moderated and displayed posters as well as oral abstracts. This culminated in the young investigator’s awards to Dr. FS Ng and Dr. JH Tuan.
FS Ng – Modulating Gap Junctional Coupling with AAP10 and Carbenoxolone Reduces the Incidence and Delays the Onset of Reperfusion Arrhythmias Following Regional Ischaemia
JH Tuan – Regional fractionation and dominant frequency in persistent Atrial Fibrillation: Effects of left atrial ablation and evidence of spatial relationship
The HRC 2009 was enjoyable, educational and accessible, with a nice balance between cutting edge and real world patient management. Next years’ congress can be highly recommended to all health care professionals involved in the management of patients with cardiac rhythm disorders.
Heart Rhythm Congress 2010, 3rd-6th October Birmingham, U.K.
Published on: November 18, 2009
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