What's New for UK Cardiology Practice from EHRA 2021?

Dr Sukh Nijjer and Dr Afzal Sohaib discuss the key developments from the European Heart Rhythm Association (EHRA) Congress.

This transcript has been edited for clarity.

Welcome to this Medscape UK video. Today we're going to be talking about the Heart Rhythm Congress from the European Society of Cardiology (EHRA). I'm Dr Sukh Nijjer. I'm a consultant cardiologist working in London, and today I'm joined by a friend and colleague, Dr Afzal Sohaib, who is a consultant cardiologist specialising in electrophysiology working at Bart's Heart Centre.

Afzal, why don't we talk about some of the key messages that have come out of this particular meeting? What were some of your highlights from the meeting this year?

Dr Afzal Sohaib

Hi, Sukh, it's great to talk to you. One of my highlights was probably the STROKESTOP trial. This was presented by Dr Emma Svennberg (Karolinska Institute, Danderyd Hospital, Stockholm) during the late breaker session, and it looked at systematic screening for AF. So this is a really interesting question, because we know that if you screen for more AF, you'll find more AF, and you'll find a lot of asymptomatic AF. But what we don't know is whether these systematic screening programmes confer a prognostic benefit. So the STROKESTOP study tried to look into this. It was a very large study. And they found that over a 7 or 8 year period, actually, there was a prognostic benefit in terms of stroke risk to screening for AF.

What was really interesting is that the difference between the two groups was really, really quite small actually, and the Kaplan Meier curves only really started diverging after about 6 years. The other thing which was really interesting is that in the arm randomised to screening, a lot of the patients who were randomised to screening refused to participate, which is really interesting. And the characteristics between the groups of patients who accepted screening versus those who didn't, were actually quite different. So the ones who refused screening tended to be a little bit sicker, have a few more comorbidities.

The screening method required twice-daily self-monitoring of ECGs over a number of days. So it was a little bit intensive. But the fact that it was spread over a number of days probably meant that the yield of AF detection was probably slightly higher. So it will be interesting to see how this rolls out into guidelines across the world. Interestingly, in the United States, and the United Kingdom, their various national screening bodies actually don't advocate a systematic screening system for atrial fibrillation like you would have for cervical smears or mammograms, for example.

So whether this translates into clinical practice in other parts of the world will be interesting.  

Race 3

The other study, which I thought was really interesting was the 5 year data from the RACE 3 trial. 

So risk factor management has been very much the hot topic in management of atrial fibrillation over the last few years. And this is one of the earliest studies which was out of the block. And the year 1 results were presented at ESC a couple of years ago. 

This study looked at people with early persistent AF and evidence of left ventricular impairment, and looked at very targeted risk factor management. So in short, people who are randomised to treatment were started on a mineralocorticoid receptor antagonist, on a statin, and they were engaged in cardiac rehabilitation as well and general lifestyle modification to optimise their cardiovascular risk factors. 

At 1 year, it seemed as though the people who were randomised to the treatment arm were more likely to be in sinus rhythm than the ones who were randomised to standard of care. 

So that's really interesting. I was expecting that trial to be positive, I was expecting if anything, the treatment arm to actually have a much higher rate of sinus rhythm than they did. So it was really interesting. I don't know why that decay occurs over 5 years. I know some of the reasons proposed by others, but I still didn't expect that to be honest.

 Dr Nijjer

I suppose the key message here is to not feel downhearted with this outcome, not to think that there's no point in managing risk factors. It's to try and look at the patient as a whole, rather than just a few individual parameters. An AF patient isn't just AF, there's lots of other factors that need controlling, including getting their weight down, including sleep apnoea, if that is a factor. Are you in your routine clinical practice, looking for sleep apnoea in these patients? 

Dr Sohaib

I tend to use simple questions, rather than doing sort of a comprehensive sleep study on all my patients. I know there's some people who advocate doing that. It's interesting with sleep apnoea, we have a lot of observational data which suggests that treating sleep apnoea is important in these patients. And there's lots of basic science to support that as well. But again, we lack a randomised control trial, a big randomised control trial where we randomise people to CPAP versus not, and see the outcomes in terms of AF burden. 

I suspect that work is very much underway, because it's such a hot topic. 

Dr Nijjer

What other areas caught your interest from this particular meeting?

Dr Sohaib

So there are quite a few interesting documents which were released during this meeting. 

There was a preview of the new CRT and pacing guideline, which is going to be released at the ESC Congress in August. And we got a sneak preview of the role of His bundle pacing in the new guideline. So this is a very hot topic as well. Conduction system pacing, trying to engage the His bundle and ensure that you have more physiological activation of the ventricles when you're pacing. 

Again, there's increasing experience with this technique now.

But what we do lack again here, is a randomised control trial to suggest that this is better than conventional pacing, both for bradycardia and for CRT. 

So we know that if we pace the His bundle, that we can in certain patients reverse their left bundle branch block and potentially that's a much neater way of offering cardiac resynchronisation.  

Conduction system pacing, very much featured in lots of different parts of the programme in this meeting. There are a lot of advocates of it. We also heard about left bundle branch pacing as well, which potentially offers some advantages over His bundle pacing in terms of long-term lead parameters and learning curve. So it's good to see some of those educational sessions on that as well. 

Dr Nijjer

And just to finish off, you mentioned some documentation that's changed. I know there's a hugely popular document that often gets used quite heavily. I know that I tend to look at it, and you've looked at it as well, that gives tips and tricks on the use of the novel oral anticoagulants (NOACs), or the direct oral anticoagulants (DOACs), such as the drugs like apixaban and rivaroxaban, and others like that, can you talk about that new document?

Dr Sohaib

Yeah, so we have the fourth edition of that, which was released. As you say, it's a very practical guide, it helps to highlight some of the differences between the different NOACs which are available. And there's lots of practical guides on managing certain clinical scenarios, such as significant renal impairment, or people who've had a recent PCI, for example, and you're trying to figure out the timing of when to stop antiplatelets in some of those patients.

There have been some tweaks to it. I mean I had a look through, I couldn't spot any major changes from some of the previous editions. But if you dig through, there are some subtle changes. As always, it's a very, very popular document. It’s very practical for anyone who's involved in prescribing NOACs and DOACs in their day-to-day clinical practice.

Dr Nijjer

My take home always from looking at that particular document is this common assumption that these medications don't have any other drug interactions. We often think of warfarin, and coumadin, and the other anti-vitamin K antagonists as being full of interactions and these newer drugs being free from interactions. But in fact, there are plenty, and they can interact with HIV medications, protease inhibitors, and antifungals that are commonly used such as ketoconazole. So we just need to keep those in mind if we're dosing them. And the guidelines actually even recommend measuring the DOAC levels in the blood, which is something that I’ve never really, we've never seen in clinical practice, and certainly not easily available in our local centres, but certainly some hospitals are doing, so that's quite eye opening for me.

Dr Sohaib

Yeah, it is interesting isn’t it? When NOACs first came out, we thought that's it, that’s the end of the anticoagulation clinic, and it's a very easy drug to use, and you just start it and then you forget about it. But actually, now that we're learning more and more about these drugs, we actually know that they're actually quite a lot of hard work, and do require a decent amount of monitoring and a lot of thought, especially when you're prescribing other medications or planning procedures, or titrating doses. If patients' renal functions go off, you have to always have at the back of your mind that the patient is on a NOAC, and do you need to adjust the dose or stop it, or convert to warfarin or something else. So, I think it's a practical guide. And it just highlights that these aren't easy drugs to use, but you know, they are important, but we do need to use them properly.

Dr Nijjer

I'd advocate all our viewers to take a look at that documentation, and we'll provide a link to it because I think it is incredibly helpful. So thank you, Afzal. Thanks for joining us today. A quick tour of some of the highlights of the meeting from this year from the European Heart Rhythm Association. And I'm glad to be speaking to you and I hope our viewers have enjoyed our discussion. 

Dr Afzal Sohaib, Consultant Cardiologist, Barking, Havering, & Redbridge University Hospitals NHS Trust and the Bart's Heart Centre, London. Honorary Clinical Research Fellow, Imperial College London. Dr Sohaib has no relevant disclosures.

You can follow Dr Sukh Nijjer on Twitter.