ESC Congress 2017 In Review -- Main Edition - 15C

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Compared with other anti-anginal drugs, only
ivabradine and trimetazidine have an additive effect with
ß-blockers.30-33 Ivabradine added to bisoprolol improves
exercise capacity more than bisoprolol uptitration.34
Thus, the evidence shows that combination therapy with
ivabradine and a ß-blocker improves tolerability, exercise
capacity, and quality of life in patients with angina.
José R. González Juanatey, MD, PhD, University
Hospital, Santiago de Compostela, Spain, discussed the
role of combination therapy in meeting the needs of
patients with angina. He used a case study to demonstrate the therapeutic issues. A 70-year-old man with
hypertension, hypercholesterolaemia, and chronic ischaemic heart disease had PCI with drug-eluting stent
implantation following STEMI. At hospital discharge, he
was taking ASA plus ticagrelor, atorvastatin, perindopril,
and bisoprolol but experienced chest discomfort during
exercise.
Based on the evidence of ivabradine's effectiveness,
Dr Juanatey recommended adding ivabradine and further increasing the ß-blocker dose for this patient.
Ferrari et al recently published a consensus statement on the treatment of angina with OMT.35 Although
Figure 4. Possible Combinations of Drugs According to Different
Comorbidities

TRIM*RAN

BB
VER*DILT

TRIM*RAN

High HR
≥ 70 bpm
Atrial
fibrillation

DHP
VER*DILT
NIC

Heart failure

TRIM*NITR
RAN

BB * IVAB

DHP
VER*DILT
NIC

DHP
NITR*NIC
TR
NI
C* N
NI RA
P* IM*
DH TR

DHP
NITR*NIC
IVAB

BB
VER*DILT
IVAB

Bradycardia

Myocardial
ischaemia

Left
ventricular
dysfunction
TRIM
IVAB*RAN
NITR
BB

BB
DHP*VER
DILT*NITR
NIC

Hypertension

Hypotension

BB*VER
DILT*DHP
NITR*NIC

BB
VER*DILT
IVAB

TRIM*RAN
IVAB

NON

AB
*IV
AN
*R
M
I
TR

Preferred
All possible
Co-administered
Contraindicated or caution needed

BB, beta-blockers; DHP, dihydropyridine calcium-channel blockers; DILT,
diltiazem; HR, heart rate; IVAB, ivabradine; NIC, nicorandil; NITR, nitrates; RAN,
ranolazine; TRIM, trimetazidine; VER, verapamil.
Source: Ferrari F et al. A 'diamond' approach to personalized treatment of
angina. Nature Reviews Cardiology. doi: 10.1038/nrcardio.2017.1038.

clinical guidelines classify antianginal drugs as first or
second choice, all of these agents have similar efficacy
and level of evidence, and no survival benefit. Because
patients with stable ischaemic heart disease and
chronic stable angina can have multiple comorobidities
and angina can result from different pathologies, the
authors recommend a more individualised approach to
management. The 'diamond' approach proposes drug
combinations based on the patient's comorbidities and
underlying conditions, rather than a hierarchy of firstand second-choice treatments (Figure 4).
In conclusion, angina is a complex syndrome with
many causes beyond obstructive CAD and multiple
mechanisms often occur in the same patient. An emphasis on a cellular basis, with new taxonomy for angina in
the absence of obstructive CAD, is likely to advance this
field. An individualised approach to treatment, based
on a patient's underlying pathology and comorbidities,
with an emphasis on combination therapy, will optimise
angina control.
Management of Heart Failure
Michel Komajda, MD, Université Pierre et Marie Curie,
Paris, France, provided a snapshot of heart failure (HF)
treatment and adherence to guidelines. Pharmacologic
treatment for HF with reduced ejection fraction has
been successful, halving mortality from HF between
1991 and 2010. This is not true for hospitalisations, which
have increased since 2002.36 An ESC registry analysis
found that 43.9% of HF patients were readmitted during a median 349-day follow-up, 56.4% of them for HF.37
In the QUALIFY global registry, including 7,092 outpatients with worsening HF, prescription rates were:
ß-blockers, 86.7%; mineralocorticoid receptor antagonists (MRA), 69.3%; angiotensin-converting enzyme
inhibitors, 65.7%; ivabradine, 33.4%; and angiotensin
receptor blockers, 21.5%.38 Guideline adherence was
good in 67%, moderate in 25%, and poor in 8% of
patients. At 18 months, follow-up, patients with good
adherence at baseline had significantly better survival
than those with moderate or poor adherence.
According to Dr Komajda, the rate of HF drug prescribing in real life is satisfactory and improving,
although underdosage remains a major issue worldwide.
Timing optimisation of HF treatment is critical for
improving outcomes after discharge, noted Martin R.
Cowie, MD, Imperial College London, London, United
Kingdom. The 2016 ESC HF guidelines recommend optimisation of oral HF therapy and management of comorbidities at predischarge to prevent early readmission
and improve symptoms, quality of life, and survival.39
Additionally, the National Institute for Health and Care

This peer-reviewed article was based on scientific-clinical content presented at the ESC (European Society of Cardiology) Congress 2017. The content of this article
was entirely developed by Content Ed Net Medicom, and the opinions expressed herein do not necessarily represent those of the European Society of Cardiology, nor
of SERVIER. The development of this article was supported by SERVIER. This material is intended for educational purposes.

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