ESC 2017: cardiovascular disease research

European Society of Cardiology 2017, focusing in on those relating to diet and nutrition and their link to cardiovascular disease
ESC 2017 was held in Barcelona and saw over 500 expert sessions and 11,000 abstracts contributing to global awareness of the latest clinical trials and breakthrough discoveries in the field of cardiovascular diseases (CVDs) © Sandor Somkuti

SEQ outlines some of the announcements at the European Society of Cardiology 2017 event, focusing in on those relating to diet and nutrition and their link to cardiovascular disease

In August 2017, SciTech Europa Quarterly travelled to Barcelona, Spain to attend the European Society of Cardiology annual congress, ESC 2017. This event, which saw over 500 expert sessions and 11,000 abstracts contributing to global awareness of the latest clinical trials and breakthrough discoveries in the field of cardiovascular disease (CVD), was held in the Spanish city just a week after a terrorist attack saw 14 people die and over a hundred others injured.

At the conference, ESC president Professor Jeroen Bax said: “CVD is the leading cause of all deaths (31%) around the world. It claims the lives of more than 17.5 million people a year. ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness. Let’s not forget that 80% of CVD is preventable. Prevention must be emphasised. That is why the ESC included a public health event in downtown Barcelona, just a week after the terrible attacks in the city.  These acts, meant to terrorise and disrupt, only succeed if we allow them to succeed. ESC Congress was determined to proceed as planned and it was a complete success.”

The 2017 instalment of the European Society of Cardiology congress featured 20 Late Breaking Clinical Trials, 12 Late Breaking Registry Results and 12 Clinical Trial Updates, four new ESC Clinical Practice Guidelines and 4,515 abstracts. “This has been one of the most exciting and comprehensive scientific programmes yet,” said Professor Stephan Achenbach, Chair of the Congress Programme Committee. “Major studies were presented reflecting the excellent scientific content submitted to our congress. Some of them will effectively change practise and move cardiology to new directions.”

The guidelines unveiled by the ESC at the event cover valvular heart disease, acute myocardial infarction with patients with ST-segment elevation (ANTI-STEMI), dual antiplatelet therapy (DAPT), and peripheral arterial disease (PAD). They have been developed by expert task forces and peer reviewers provide a valuable clinical decision-making tools for clinicians by summarising the available evidence on these topics.

Commenting on the congress, Professor Steen Dalby Kristensen, Chair of the ESC Media Committee, said: “We had many interesting studies presented this year but if I had to highlight one study, I would quote the COMPASS trial. This is a very important randomised study showing that very low dose of rivaroxaban added to low dose of aspirin improves outcome in patients with stable coronary and/or peripheral artery disease.”

Notable trials at ESC 2017

Other notable trials presented in Barcelona that will change practice and knowledge have been highlighted by the European Society of Cardiology after the event. These include:

  • CANTOS: The IL-1β inhibitor canakinumab lowers the risk of cardiovascular disease and lung cancer risk by reducing inflammation;
  • CASTLE AF: Catheter ablation improves outcomes for patients with left ventricular dysfunction and atrial fibrillation;
  • DETO2X-AMI: Oxygen therapy does not improve survival in patients with heart attack symptoms; and
  • PURE: High carbohydrate intake is linked to worse total mortality and non-cardiovascular (CV) mortality outcomes, while high fat intake is associated with lower risk. The large dietary study showed that even relatively moderate intake of fruit, vegetables and legumes such as beans and lentils may lower a person’s risk of cardiovascular disease (CVD) and death.

The event saw many other interesting topics being discussed and exciting developments being announced. For instance, researchers at the conference called for a reconsideration of global dietary guidelines in light of new data presented at the event on fat intake and cardiovascular risk and mortality.

What is the link between carbohydrate intake and CVD?

The Prospective Urban-Rural Epidemiology (PURE) study, which presented its results at the conference, drew on findings from more than 135,000 individuals from 18 low, middle and high-income countries to demonstrate that high carbohydrate intake is linked to worse total mortality and non-cardiovascular (CV) mortality outcomes, while high fat intake is associated with lower risk.

Study investigator Dr Mahshid Dehghan, from the Population Health Research Institute, McMaster University in Ontario, Canada, said: “Our findings do not support the current recommendation to limit total fat intake to less than 30% of energy and saturated fat intake to less than 10% of energy.

“Limiting total fat consumption is unlikely to improve health in populations, and a total fat intake of about 35% of energy with concomitant lowering of carbohydrate intake may lower risk of total mortality. In fact, individuals with high carbohydrate intake, above 60% of energy, may benefit from a reduction in carbohydrate intake and increase in the consumption of fats.”

The study recorded the consumption of carbohydrate, total fat and types of fat were recorded using country-specific, validated food frequency questionnaires, and associations were assessed with CV disease and mortality.

Among the 5,796 deaths and 4,784 major cardiovascular events over a median follow-up of 7.4 years, the researchers noted that carbohydrate intake in the highest versus lowest quintile was associated with a significant 28% increased risk of total mortality (hazard ratio  [HR] 1·28; 95% CI 1·12-1·46, highest vs lowest quintile category, P≤0·0001) but not cardiovascular disease (CVD) risk.

Conversely, total fat intake in the highest versus lowest quartile was associated with a significant 23% reduction of total mortality risk, an 18% reduced risk of stroke, and a 30% reduced risk of non-CVD mortality.

Each type of fat was associated with significantly reduced mortality risk: 14% lower for saturated fat, 19% for mono-unsaturated fat, and 20% for polyunsaturated fat. Higher saturated fat intake was also associated with a 21% decrease in stroke risk.

The researchers also examined the impact of fats and carbohydrates on blood lipids in the same PURE study participants.

Consistent with other reports from Western countries, they found that while LDL (so-called ‘bad’ cholesterol) increases with higher intakes of saturated fat, HDL (‘good’ cholesterol) also increases – so the net effect is a decrease in the total cholesterol/HDL ratio.

They found that LDL cholesterol (the basis of many dietary guidelines) is not reliable in predicting effects of saturated fat on future cardiovascular events. Instead, ApoB/ApoA1 provides the best overall indication of effect of saturated fat on cardiovascular risk among the markers tested.

Dehghan said: “Focusing on a single lipid marker such as LDL-C alone does not capture the net clinical impact of nutrients on cardiovascular risk.

“For decades, dietary guidelines have focused on reducing total fat and saturated fatty acid (SFA) intake based on the presumption that replacing SFA with carbohydrate and unsaturated fats will lower LDL-C and should therefore reduce CVD events.”

She added that much of the evidence behind this approach has been from studies of Western populations where nutritional excess is a reality, concluding: “PURE provides a unique opportunity to study the impact of diet on total mortality and CVD in diverse settings, some settings where over-nutrition is common and others where under nutrition is of greater concern.”

How does fruit and veg intake lower CVD risk?

The PURE team also found that even relatively moderate intake of fruit, vegetables and legumes such as beans and lentils may lower a person’s risk of cardiovascular disease and death.

Dr Andrew Mente, from the Population Health Research Institute, McMaster University, Hamilton, Canada, who led this particular study, explained: “To our knowledge, this is the first study to report on the associations of fruit, vegetable and legume intake with CVD risk in countries at varying economic levels and from different regions,

“Previous research, and many dietary guidelines in North America and Europe recommended daily intake of these foods ranging from 400 to 800 grams per day, but this is unaffordable for many people in low to middle-income countries. Our findings indicate that optimal health benefits can be achieved with a more modest level of consumption, an approach that is likely to be much more affordable.”

The PURE analysis, investigators assessed associations between fruit, vegetable, and legume consumption at baseline and risk of cardiovascular disease and mortality after a median of 7.4 years of follow-up.

Looking at the total of 5,796 deaths, 1,649 CV deaths, and 4,784 major cardiovascular disease events, and adjusting for demographic, lifestyle, health, and dietary factors, the study showed greater fruit, vegetable, and legume intake was associated with lower total mortality, and non-CV mortality.

Of particular importance, an intake of 3-4 servings per day (equivalent to 375-500 grams per day) was just as beneficial on total mortality as higher amounts (hazard ratio [HR] of 0·78; 95% CI 0·69 to 0·88).

Looking at the dietary components separately showed that the benefits were attributable to fruit and legumes, with vegetable intake not significantly associated with improved outcomes.

Specifically, compared to fewer than three servings of fruit per week, more than 3 per day was associated with an 18% reduced risk in non-CV mortality (HR: 0·82: 95% CI 0·70 to 0·97; P-trend=0·0008), and 19% reduction in total mortality (HR: 0·81; 95% CI 0·72 to 0·93; P-trend<0·0001).

Regarding legumes, higher consumption was associated with significant reduction in both non-CV mortality and total mortality risk.

As compared with less than one serving of legumes per month, more than one serving per day was associated with an 18% reduction in non-CV mortality (95% CI 0·70 to 0·97; P-trend=0·0019) and a 26% reduction in total mortality (95% CI 0·64 to 0·86; P-trend=0·0013).

Finally, comparing vegetable preparation, the study showed a trend towards lower risk of cardiovascular disease and death with raw versus cooked vegetable intake “but raw vegetables are rarely eaten in South Asia, Africa and Southeast Asia,” Mente said.

“Since, dietary guidelines do not differentiate between the benefits of raw versus cooked vegetables – our results indicate that recommendations should emphasize raw vegetable intake over cooked.”

In conclusion, Mente added that findings from the study “are robust, globally applicable and provide evidence to inform nutrition policies. Many people in the world don’t consume an optimal amount of fruit, vegetables and legumes. The PURE data add to the substantial evidence from many studies and extend them globally.”

Is coffee linked to lower mortality rates?

Research presented at ESC Congress also revealed that higher coffee consumption is associated with a lower risk of death. The observational study in nearly 20,000 participants suggests that coffee can be part of a healthy diet in healthy people.

The purpose of this study was to examine the association between coffee consumption and the risk of mortality in a middle-aged Mediterranean cohort. The study was conducted within the framework of the Seguimiento Universidad de Navarra (SUN) Project, a long-term prospective cohort study in more than 22,500 Spanish university graduates which started in 1999.

Dr Adela Navarro, a cardiologist at Hospital de Navarra, Pamplona, Spain, said: “Coffee is one of the most widely consumed beverages around the world. Previous studies have suggested that drinking coffee might be inversely associated with all-cause mortality but this has not been investigated in a Mediterranean country.”

She added: “In the SUN project we found an inverse association between drinking coffee and the risk of all-cause mortality, particularly in people aged 45 years and above. This may be due to a stronger protective association among older participants,” concluding: “Our findings suggest that drinking four cups of coffee each day can be part of a healthy diet in healthy people.”

What is the link between salt intake and heart failure?

Staying with the theme of diet and nutrition, other research presented in Barcelona argued that high salt intake is associated with a doubled risk of heart failure.

The presentation entitled ‘Salt intake and the risk of heart failure’ explained that a 12-year study in more than 4,000 assessed the relationship of salt intake and the development of heart failure. Estimation of individual salt intake is methodologically demanding and therefore suitable population-based cohorts are rare. This study used 24 hour sodium extraction, which is considered the gold standard for salt intake estimation at individual level.

This study was a prospective follow-up study of 4,630 randomly selected men and women aged 25 to 64 years at baseline who participated in the North Karelia Salt Study and the National FINRISK Study between 1979 and 2002 in Finland. Baseline data collection included a self-administered questionnaire on health behaviour, measurements of weight, height and blood pressure, a venous blood sample for laboratory analysis, and collection of a 24 hour urine sample.

Professor Pekka Jousilahti, research professor at the National Institute for Health and Welfare, Helsinki, Finland, said: “High salt (sodium chloride) intake is one of the major causes of high blood pressure and an independent risk factor for coronary heart disease (CHD) and stroke. In addition to CHD and stroke, heart failure is one of the major cardiovascular diseases in Europe and globally but the role of high salt intake in its development is unknown.”

He added: “The heart does not like salt. High salt intake markedly increases the risk of heart failure. This salt-related increase in heart failure risk was independent of blood pressure.

“People who consumed more than 13.7 grams of salt daily had a two times higher risk of heart failure compared to those consuming less than 6.8 grams. The optimal daily salt intake is probably even lower than 6.8 grams. The World Health Organization recommends a maximum of 5 grams per day and the physiological need is 2-3 grams per day.”

“Studies in larger, pooled population cohorts are needed to make more detailed estimations of the increased heart failure risk associated with consuming salt,” the researcher concluded.

What role does e-health play?

The ESC congress also hosted an area dedicated to digital health, highlighting the growing array of digital resources to support and improve the healthcare sector.

The space hosted 15 digital health-related start-ups, selected by ESC and 4YFN, a Mobile World Capital programme, who displayed their solutions throughout the event, all with the aim to improve people’s lives in the areas of: eHealth, telemedicine, prevention, genetics, therapy and rehabilitation.

Digital health is expanding rapidly and is now the third largest industry in the European health sector, after pharmaceuticals and medical devices.

From digital medical records to big data and self-monitoring on smart phones, digital health is dramatically changing healthcare and the ways in which doctors and their patients both deal with a growing list of medical conditions. The ESC is playing an ever-increasing role in all aspects of the eHealth agenda by helping to develop, assess and implement effective innovation in order to support and improve cardiovascular health.

The ESC is also part of the conversation on a policy and regulatory level, with ESC representatives working alongside the European Commission’s expert groups on eHealth to ensure the interests of cardiovascular professionals and their patients are fully represented.

The ESC Congress contributes to global awareness of the latest clinical trials and breakthrough discoveries, and as the few topics and discoveries highlighted here demonstrate, the event continues to break new ground in the field of cardiology and is therefore likely to continue to be the world’s largest and most influential cardiovascular scientific conference, and one that SciTech Europa Quarterly will continue to cover.

This article will appear in SciTech Europa Quarterly issue 26, which will be published in March, 2018.

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