Ileana L. Piña, MD, MPH


October 10, 2016

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Hi. This is Ileana Piña from Albert Einstein College of Medicine in the Bronx, New York. This is my blog from the European Society of Cardiology (ESC) meeting. I heard today that there are 34,000 attendees, making this probably the largest cardiology meeting in the world. And you can hear the excitement in the hallways and in the presentations. It's really invigorating to be here.

Two important things at this congress are the releases of an important guideline[1] and an expert consensus position paper.[2] I'll address the guideline first, and it's the guideline on atrial fibrillation. Those of you who have watched my blogs before know that I deal with heart failure every single day at work, but I also deal with atrial fibrillation. There is an unknown understanding of the contributions of heart failure to atrial fibrillation, and these guidelines actually tackle that head-on. Often I find that clinicians, our residents, or house staff, focus on the atrial fibrillation without realizing that what's underneath is heart failure, and that if you don't treat the heart failure it's going to be a lot harder to treat the atrial fibrillation.

These guidelines also stress that if you treat patients appropriately, particularly with beta-blockers, you may actually prevent atrial fibrillation in these patients. In fact, even though we do that, it is a novel concept and view of the situation. Atrial fibrillation that has a rapid ventricular rate may be a reason for an admission, and these patients usually come through the emergency department.

Another important point that I am trying to make at my institution is the use of IV diltiazem or IV verapamil to slow down the atrial fibrillation. It may work, but if you don't know what's underlying in that ventricle, it can be potentially dangerous. You can put a patient in florid heart failure with IV diltiazem. So if you're ever uncertain about the ventricular function, you're always much safer using IV metoprolol.

These guidelines also encourage the use of NOACs [novel oral anticoagulants] in appropriate patients and they cover the CHA2DS2-VASc score, which puts the gender issue very much in the forefront. Atrial fibrillation in women has a high morbidity and mortality and it also cannot be ignored. It's not just something routine.

Then the question of ablation comes up—and we will address ablation in another interview—whether to perform early ablation rather than trying to control the rate or cardiovert the patient. Certainly, if the patient's in trouble and they're getting hypotensive, then you need to do a transesophageal echo so that you can determine whether there is any thrombus in the left atrium. If there isn't, then cardioversion is the right step.

Important guidelines are available from the European Heart Journal.[1] You can get them online; you can download the whole thing, including the executive summary.

The other interesting paper is about oncology and cardiotoxicity.[2] This is becoming a huge subject, at least in the United States but perhaps worldwide. Many of you know that patients are surviving their cancers—that some of the drugs, in particular some of the antibody-based therapies, have saved a lot of lives. For years, I have been seeing women treated with breast cancer therapies who end up with heart failure. How to treat these women is also a subject of this important consensus document.

So, we are broadening our aspect of the heart failure syndrome, including heart failure and hypertension. The consensus statement includes some excellent tables showing the doses of the anticancer drugs and gives suggestions about treatment. Even more important than treatment is how do we know which one of these patients is actually going to have a damaged left ventricle from the cancer therapy? We now have some very interesting techniques, especially using echocardiography and MRI, that may tell us way ahead of time—before the ejection fraction drops, before the ventricle apparently remodels—when to work very closely with the oncologist. The field of cardio-oncology is blossoming. It's a very important field, as these patients are surviving. Our oncology colleagues have done an amazing job treating cancer in the past 10 years.

I hope you get these guidelines and consensus statements for yourself. This is Ileana Piña, signing off. Have a great day.


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