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.

New anticoagulants…

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.

…and antiarrhythmic agent

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 pacing systems

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.

Treating complex arrhythmias

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:

Awards

Charles Lobban Volunteer Award for Outstanding Contribution to Arrhythmia Services 2009

Winner – Julie Fear

Award for Outstanding Contribution to the Management of Inherited Cardiac Conditions 2009

Winner- Dr. Anna Maria Choy

Highly Commended

- Miss Cath Owen

- Dr. Pascal McKeown

Award for Outstanding Contribution to Arrhythmia Management in Primary Care 2009

Winner – Miss Adele Graham

Highly Commended –Dr. Du Xin

Team of the Year Award 2009

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.

Young Investigators Awards

Basic Science

FS Ng – Modulating Gap Junctional Coupling with AAP10 and Carbenoxolone Reduces the Incidence and Delays the Onset of Reperfusion Arrhythmias Following Regional Ischaemia

Clinical

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, 3^rd-6^th October Birmingham, U.K.

www.heartrhythmcongress.com

It is unclear what chemical component of particulate matter (PM) is responsible for these adverse cardiovascular effects, but smaller size PM appears to be more strongly correlated. Further difficulties in assessing exposure arise when data are derived from fixed monitoring stations because of differences between outdoor and indoor PM pollution, the latter of which often is the more relevant.

Systemic inflammation and prothrombotic conditions that are elicited by PM in the lung are thought to represent the underlying mechanism of cardiotoxicity, but other mechanisms have been inferred, whereby inflammation and thrombosis may simply co-exist.

Personal exposures to PM₁₀, PM_2.5, and PM_0.25, was measured over 24 h in 39 patients (36 males, 3 females, mean age 60.3 years), with prior myocardial infarction (> 6 months). Simultaneously, a 24 h ECG was recorded and then analysed for heart rate variability (HRV) and ventricular arrhythmias. Breath condensate and blood samples also were collected at the end of monitoring to measure several indexes of inflammation. Negative correlation was found between HRV and exposure to PM_0.25 in a group of patients not taking ß-blockers. More severe ventricular arrhythmias were observed at the highest concentrations of PM₁₀ and PM_2.5. Indexes of inflammation in either breath condensate or blood did not correlate with PM exposures.

The study shows that exposure to ultrafine particles is associated with autonomic dysregulation in selected patients with myocardial infarction. More severe arrhythmias occur at the highest exposure to large particles. Nevertheless, the underlying mechanisms remain hypothetical because inflammation may be evoked by PM or be related to the disease itself, these workers conclude.

Reference:

Individual exposure to particulate matter and the short-term arrhythmic and autonomic profiles in patients with myocardial infarction. Folino F, Scapellato L, Canova C, et al. European Heart Journal (2009) 30, 1614-1620.

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.

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 the Europace 2009 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, mark

“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), should help to standardise health resources by promoting knowledge of the status and bringing it to the attention of all public authorities” explained Professor 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 Professor 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.

Professor 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, Professor 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 Professor 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 Professor Wolpert.

References

1. EHRA, the European Heart Rhythm Association, aims to serve as the leading organisation in the field of arrhythmias and electrophysiology in Europe, and to attract physicians from all of Europe and beyond to foster the development of this area of expertise. EHRA is a registered branch of the European Society of Cardiology (ESC). EHRA is based in Sophia Antipolis, France. Visit us at www.escardio.org/EHRA
2. Full version of the white book available on:
 http://www.escardio.org/communities/EHRA/publications/Pages/white-book-project.aspx