cardiovascular continuum including atherosclerosis'regression in the coronary artery and the recommendeduse of beta blockers in hypertension, especially whensympathetic hyperactivity or complications are present,such as, in CAD or CHF, a reduction of morbidity andmortality were seen when beta-blockers were used inhemo-dynamically stable cases, achieving 55-60bpm,without cardiogenic shock.

Omar Awwad (Egypt) discussed the role today of newbeta-blockers in hypertension management, especiallyin CAD conditions, where they have been proven to beeffective for primary and secondary prevention. The highselectivity of these compounds is crucial inunderstanding their positive effects and to encouragetheir wider use, e.g. in the reduction of diabetes onsetor related cardiovascular complications, their neutraleffects on lipids and erectile dysfunction and having nocontraindications in their use when there is peripheralartery disease and COPD.

Stefano Taddei (Italy) explained the mechanisms ofaction and clinical effects of ACEIs and ARBs inhypertension. While both are effective in decreasing

Pham Gia Khai (Vietnam) as scientific organizerwelcomed the 200 participants to the meeting. Theparticipants were cardiologists, internists and generalpractitioners, coming mainly from Vietnam, India, China

and Singapore. Following the welcome, he introducedthe main topics and learning objectives of the meeting.

Pham Nguyen Vinh (Vietnam) summarized the keypoints from the main guidelines for the managementof hypertension available today (NICE 2011, CHEP 2012).They are: a target blood pressure <140/90mmHg inpatients with non-diabetic chronic kidney disease; therole of aldosterone antagonists in patients with CHF; atherapeutic algorithm for managing resistanthypertension; and the recommendation to use a singlepill combination to improve adherence and bloodpressure.

Brian Tomlinson (China) explained the cardio-protective effects of beta-blockers in relation to the

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NEWSLETTERThe Serono Symposia International Foundation newsletter | Educational activities 2013

CARDIOVASCULAR

23rd European Meeting onHypertension & CardiovascularProtection (ESH)14-17 June 2013 - Milan, Italy ON PAGE 3

International School ofEchocardiography in Anesthesiaand Critical Care Medicine27-29 June 2013 - 26-28 September 2013Pisa, Italy ON PAGE 4

2nd European-Middle East Forum on“Managing cardiovascular riskfactors in clinical practice”6 December 2013 - Istanbul, Turkey ON PAGE 5

EDUCATIONALACTIVITIES

HIGHLIGHTS

SSIF Educational events Programme 2014 ON PAGE 7

2014 Asia-Pacific cardiovascularsymposium“Managing cardiovascular riskfactors to prevent the fatal end ofcardiovascular continuum”1-2 March 2014 - Guangzhou, China

International Course on Echocardiographic DeformationIndexes24-25 March 2014 - Milan, Italy

[ ]This year’s symposium focused on guidelines for managing hypertensionand chronic heart failure and on anti-thrombotic therapy in cardiac

ischemic disease and atrial fibrillation.

2013 Asia-Pacific Cardiology SymposiumFrom hypertension to heart failureInterruption of the cardiovascular continuum6-7 April 2013 - Hanoi, Vietnam

Satisfaction rate:% Very Satisfied / Satisfied: 97%

blood pressure and are protective of renalfunction, only the ACEIs' seem to be effective inreducing CAD-related and overall mortality. Thisis possibly due to the class-specific block ofbradykinin degradation, with positive effects onvessels' tone, atherosclerosis, coagulation,endothelial function and cardiac structure andperformance.

Harry Struijker-Boudier (The Netherlands)highlighted the problem of adherence totreatment in hypertension and the low rate ofdisease control in such patient as, only 25% havea blood pressure of <140/90mmHg. Lack ofpatient compliance is one of the main factorstogether with the point that only 10-20% ofhypertensives' are controlled in mono-therapy.Single-pill fixed-dose drug combination therapycan help by improving adherence andhypertension, limiting complications and sideeffects.

Pham Gia Khai (Vietnam) explained thebenefits of lowering a high heart rate in thepresence of CAD. CAD is a factor which isresponsible for increased mortality from allcauses but especially from cardiovascularproblems where there is a heart rate >70-80bpm. The reasons for this are because it canencourage the atherosclerosis process and thenplaque rupture. The use of the GRACE score, alsoincluding heart rate, is important to evaluatepatients at risk of ischemic heart disease and toguide a proper drug therapy for preventing itsoccurrence or worsening.

Peter Yan (Singapore) reported the details andconclusions of the REACH registry, anobservational study recently published evaluatingthe effects of beta-blockers in patients with CADor with only the risk factors for it, using the non-selective drug atenolol. No differences werefound in cardiovascular events occurring in anygroup, but paradoxically a mild increase in was

seen in patients taking atenolol who were at riskof or had CAD without prior MI; this evidence hasto be confirmed and further investigated.

Eugene Reyes (The Philippines) confirmed themain role acetylsalicylic acid still has in theprimary and secondary prevention ofcardiovascular events. In the first case, it preventscardiac ischemia and related death in high risk

patients; in the second, it has robust effects in allpatients who had previous MI or stroke. The riskof side effects is moderate, mainly gastro-intestinal bleeding. Dual anti-aggregation is

convenient only in selected cases withparticularly high risk of thrombotic event.

Dang Van Phuoc (Vietnam) described themechanisms by which sympathetic hyperactivityis a key determinant of hypertension, CAD, CHF,and arrhythmias, but also in atherosclerosis,metabolic syndrome, and related complications.Once diagnosed by cardiologic examination, bloodlevels of catecholamines and microneurographyyou can counteract this unfavorable adrenergicoverdrive by, using drugs like beta-blockerswhich can help improve the management of suchconditions and outcomes.

Pham Mahn Hung (Vietnam) presentedpreliminary results from clinical trials using twonovel non-medical approaches, based onevidence of sympathetic hyperactivation andbaroreflex depression, to manage uncontrolledand resistant hypertension. Renal denervationwas shown to reduce blood pressure by 30% inabout 90% of patients measured 3 years aftertreatment, however less relevant reduction wasseen using carotid sinus stimulators, but they canbe used in combination with renal denervation ifnecessary.

Ho Huynh Quang Tri (Vietnam) talked aboutthe prevalence of AF in different cardiovasculardiseases. In hypertension 10% of patients haveAF, 45% of patients with CHF have AF and itcommonly occurs in the acute phase of MIinfluencing cardiac mortality. Beta-blockers, bymodulating atrial firing and decreasing heartrate, can prevent and treat AF in hypertension,CHF and AMI. This is the case inhemodynamically stable patients if they are givenearly, first intravenously and later orally, togetherwith amiodarone.

Shirish Hiremath (India) outlined the mainproperties of the novel anticoagulants availablefor prevention of stroke in AF, such as:dabigatran, blocking factor IIa and rivaroxaban

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The “23rd European meeting on hypertension & cardiovascularprotection”, organized by the European Society of Hypertension (ESH),was held in Milan on 14-17 June 2013. There were internationalparticipants as well as European and many important issues werediscussed concerninghypertension and relatedcardiovascular diseases. Themeeting also released to thescientific community the newESH/ESC guidelines for themanagement of hypertension,available online. Here below is asummary of the most significanttopics presented during thescientific sessions.A major topic during the meetingwas new technological solutionsfor the management of resistanthypertension. Results frompreliminary studies werepresented on two novelinterventional approaches, renaldenervation and baroreflexstimulators. The former actsmainly by reducing thesympathetic overactivity presentin such cases with significantreduction of blood pressure (up to30%) and improved quality of lifedue to the reduction ofantihypertensive agents. Baroflex stimulators are implantable vagalstimulators, to be placed close to the carotid bulb, releasing a periodicalimpulse able to significantly decrease blood pressure and heart rate.Although for both techniques confirmatory studies have to be performed,they appear quite easy to perform, with few side effects and relativelyinexpensive.Another key issue in hypertension is controlling blood pressure at night.In many cases of uncontrolled hypertension the reason is nocturnalhypertension, an important cardiovascular prognostic factor requiringdiagnosis by overnight blood pressure recording using differenttechniques, some under validation (e.g. pulse transit time).Polysonnography should be also used to better find subjects at high risk

and implement appropriate therapeutic drugs and strategies. Obstructivesleep apneas are a major determinant for nocturnal blood pressure peaksand, together with the associated hypoxia, are responsible forcardiovascular events such as cardiac or cerebral ischemia or

arrhythmias. Impairment ofcognitive function, metabolic andendocrine disturbances are alsopresent.Heart rate in hypertension andcardiovascular diseases wasanother important issue discussedduring the sessions. Heart rate isa marker of sympathetic activityand predicts cardiovascular riskand events, especially at night,arrhythmias and related mortality(over 80 bpm at rest). Tachycardiacan cause mechanical damage toperipheral organs, with reductionof blood flow and of capillarydensity, due to hypertension,increased arterial stiffness andresistance; it is also correlated tometabolic diseases, e.g. type 2diabetes and insulin resistance.The new generation of beta-blockers can reduce suchoverdrive and limit itsconsequences without metabolicor respiratory side effects and with

minimal effects on sexual function.Another key topic was arrhythmias in hypertension that in turn representa major risk for subsequent cardiovascular events, i.e. strokes.Hypertension with left ventricular hypertrophy and dilatation andassociated sympathetic overdrive predispose frequently to the onset ofatrial fibrillation, the most common type. Other factors favouring itsoccurrence are cardiac ischemic conditions, conduction-repolarizationdisorders, hypokalemia from antihypertensive drugs and hypoxicobstructive sleep apneas. Beta-blockers and blockers of the renin-angiotensin system together with antiarrhythmic drugs are used tomanage these cases together with the use of aspirin and oralanticoagulants to prevent thromboembolism.

14-17 JUNE 2013 - MILAN, ITALY

and apixaban blocking factor Xa. In comparisonwith the traditional anticoagulants such aswarfarin, the newer anti-thrombotics have fasteronset of action, shorter half-life, lower risk ofbleeding, and fewer drug interactions but mostlyhave renal excretion, do not have an antidote andare all very expensive.

Gopal Sreenivas (India) gave an update on the2012 ESC guidelines for HF management,highlighting the new concepts arising from them.These included: a wider use of mineralocorticoidreceptor antagonists; cardiac resynchronizationand coronary revascularization; use of ventricularassisting devices; trans-catheter valve

interventions and consideration of the specificclinical conditions for each approach and also themeasurement of BNP/NT-pro-BNP fordifferentiating acute from chronic HF.

Abdul Rashid Adbul Rahman (Malaysia)clarified the many benefits of using beta-blockersin all stages of CHF, arguing that theirunderutilization in such conditions is not justified.Their main effects are the reduction of heart rate,prevention of AF and improvement of leftventricular function resulting in slower diseaseprogression, improvement of prognosis, with lessneed for heart transplants and overall a reductionof mortality rates. The benefit of their use is also

confirmed in diastolic HF.Piyamitr Sritara (Thailand) gave an overview

on the role of diuretics in HF, explaining thatprevention of fluid retention is important to avoiddeterioration of heart function, edemacomplications, and hospitalizations. Education ofpatients is crucial by encouraging self-monitoringof body weight and of signs of peripheral/centraledema. Loop diuretics are the favorite ones, butalso thiazides can be used with success. Newerdrugs are being developed, such as blockers ofBNP degradation.

Cardiovascular syndromes are frequent emergencies in anesthesia andcritical care settings, and can have a significant impact on the morbidity andmortality of the patients involved. Prompt recognition of such conditions,

with the support of echocardiography performed by well-trained personnel,can help to ensure suitable therapeutic strategies in critically ill patients.

The course was divided into theoretical and practical sessions. Thetheoretical sessions focused on image formation and the physics ofultrasound, indications and contraindications for trans-esophagealechocardiography (TEE), guidelines for the use of echocardiography, andecho-anatomical correlations on animal hearts in the lab. The practicalsessions provided hands-on experience in patients with coronary arterydiseases, aortic valve disease, mitral valve disease, pericardial effusion, orundergoing mechanical ventilation and hemodynamic optimization as aresult of acute syndromes in theatre and intensive care unit.

[ ]A unique educational programme which

brings together a small group of physicians toexperience the role of echocardiography in

clinical management of critical care situations.

Satisfaction rate: % Very Satisfied / Satisfied: 100%

International School of Echocardiography inAnesthesia and Critical Care Medicine27-29 June 2013, 26-28 September 2013 - Pisa, Italy

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The Manage Hypertension online website is being developed with theguidance of a prestigious scientific committee composed of threemembers, each from a major region of the world:1. Prof. Omar Awwad, Department of Cardiology, Ain Shams University,

Cairo, Egypt 2. Prof. Harry Struijker-Boudier, Department of Pharmacology,

Maastricht University, The Netherlands3. Prof. Brian Tomlinson, Department of Medicine and Therapeutics,

The Chinese University of Hong Kong

Manage Hypertension online was launched on August 25, 2012, at theEuropean Society for Cardiology (ESC) Congress in Munich.

Manage Hypertension helping meet a growing challengeBy focusing on hypertension and cardiovascular disease SSIF aims tohelp reduce hypertension and cardiovascular diseases – with the specificaim of helping to reduce the impact of this disease on society bydelivering dedicated contining medical education for healthcareprofessionals.The Manage Hypertension online website provides backgroundinformation and e-learning materials allowing general practitioners(GPs) and specialists to have access to the latest information and to learnabout hypertension when it is convenient to them, and at their own pace.The website features the latest research alongside background materialabout many different aspects of hypertension, all presented using state-of-the-art techniques.Manage Hypertension online will be launching with conference reportsand a bibliography, together with detailed background on three key areas:• Hypertension management according to age and other comorbidities • Heart rate reduction as a goal in hypertension management • Combination of antihypertensive agentsHypertension and cardiovascular diseases are widespread worldwide,and have a deep impact on peoples’ lives and on national healthcaresystems. Currently, GPs are not well served by the dedicated medical educationavailable on the internet, and GPs especially value information focusingon intervention strategies on risk factors and life-style, screening examsfor early diagnosis in predisposed subjects, evaluation of relatedcomplications and comorbidities, and guidelines for prescribing andmonitoring therapies on targets. SSIF believes that the service will also be useful for specialists, and thatthey will appreciate information about pathogenesis of hypertension andof its complications, novel diagnostic biomarkers and refined imagingtechniques, criteria for treating less common conditions, and indicationsfor medical or interventional treatments

Manage Hypertension online

follow us on

http://twitter.com/SSIF_MHypertension

SSIF_MHypertension

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2nd European-Middle East Forum onManaging cardiovascular risk factors in clinical practice6 December 2013 - Istanbul, Turkey

The 2nd European-Middle East forum on“Managing cardiovascular risk factors in clinicalpractice” took place in Istanbul, Turkey, on 6December, attracting participants largely fromcountries in the Middle East. The discussionfocused on the management of hypertension andits related cardiovascular diseases andcomplications, but also highlighted theappropriate prevention strategies to avoid suchproblems.

G. Mancia (Italy) presented the key points of the

2013 ESH/ESC guidelines for hypertensionmanagement. He paid specific attention to thequoted level of 140/90 mmHg as the target of

standard anti-hypertensive therapy and explainedthat, to achieve this, it is very important thatdifferent drugs affecting the underlyingmechanisms are used at low dosage so as to takeadvantage of the specific site of action of each

while avoiding the side effects resulting fromlarger doses.

G. Grassi (Italy) explained the peculiar

hyperactivation of the sympathetic nervoussystem that occurs in many cases of hypertensionand is responsible for not only more resistantdisease but also a series of related disorders,such as metabolic syndrome, sleep apnea, heart

[ ]Specialists from Europe and Middle-East countriesgather in Istanbul to share their experience in the

management of cardiovascular risk factors andhypertension with related complications

Satisfaction rate:% Very Satisfied / Satisfied: 100%

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failure and cardiac arrhythmias which require more stringentpharmacological therapy and patient follow up. He also described the roleof specific agents such as beta blockers that are able to block suchproblems.

Several anti-hypertensive agents have shown cardio-protective propertiesthat can break the continuum of cardiovascular diseases. N. Bazargani (UAE)explained that the blockade of the renin angiotensin aldosterone system,especially by ACE inhibitors, seems to have beneficial effects on the heartin terms of ischemic events and arrhythmias. The same also appears to bean advantage of using beta blockers especially in the case of coronary arterydisease and chronic heart failure.

The 2012 ESC guidelines for the management of heart failure with areduced ejection fraction were discussed by A. Salustri (UAE) whohighlighted the role of ACE inhibitors and beta blockers. He also discussedaldosterone antagonists as first line therapy with ivabradine and then cardiacre- synchronisation therapy as further steps in the intervention. He alsodescribed the peculiar picture of this issue in countries in the Middle Eastwhere a multidisciplinary approach is recommended for best outcomes.

A. Coca (Spain) illustrated the occurrence of silent brain damage inhypertension that precedes the event of stroke and said that this requiresmore attention from doctors. Several studies with MRI have shown thatmicroaneurisms, lacunae, microbleeds and white matter lesions are allrelated to an early cognitive decline, detected at neurological examinations,and later to dementia. Stricter blood pressure control, especially of systoliclevels, may prevent this hidden complication.

A. Khalifa (Bahrain) provided insight into an innovative approach formanaging atrial fibrillation, focusing on ischemic stroke prevention. Today,new anticoagulants such as dabigatran or apixaban are available with bettersafety profiles and equal efficacy to traditional warfarin. He also describedmodern interventional left atrial occlusive approaches with filters ormembranes to be used when contraindications to anticoagulants arepresent.

Metabolic diseases are increasing significantly in the countries in theMiddle East as a result of the shift to a western lifestyle, which has led to apeak in cardiovascular diseases at younger ages. K. Sulaiman (Oman)explained that diabetes, obesity, dyslipidemia and smoking or khat chewingare the main risk factors, and that the conditions are often not diagnosedand that there is inadequate treatment and prevention. This leads tohypertension, stroke and myocardial infarction, resulting in increasing costsfor the local healthcare systems.

A frequent disorder found in metabolic syndrome and cardiovasculardiseases is obstructive sleep apnea, said P. Nilsson (Sweden), which can

Serono Symposia International Foundation (SSIF) is initiating aseries of activities in cardiovascular medicine, such as CMEaccredited live events and online courses that will focus theirattention on hypertension, arythmias, and cardiac, cerebral andperipheral limb ischemic diseases.

SSIF's educational offer is dedicated to healthcare professionalswho are seeking to improve their knowledge in cardiovascularmedicine thus providing the best diagnostic and therapeuticsolutions to their patients.

Visit the Cardiovascular section of the new Serono SymposiaInternational Foundation (SSIF) website.

www.cardiovascular.seronosymposia.org

Register to access free e-learning activities and receiveupdates on new events and resources.

Take a look at the SSIF cardiovascular website

trigger cardiovascular events and lead tometabolic alterations such as increasingsympathetic activity, inflammation,atherosclerosis, hypertension, cerebral-cardiacischemic events, insulin resistance and diabetes.Lifestyle changes, oral surgical interventions andC-pap are treatments that can limit suchcomplications.

M. Saleh (Egypt) described the main changesrequired in the lifestyle of patients with or at highrisk of cardiovascular disease that can prevent theoccurrence of negative events. A healthy diet withweight loss and a reduced sodium intake are of

primary importance, followed by a programme ofmoderate-to-intense aerobic physical activity.Together these measures can improvecardiovascular efficiency and performance.Stopping smoking and drinking alcohol are alsoof major importance.

Two speakers reviewed the issue of resistanthypertension. A. Manolis (Greece) defined thecriteria for resistant hypertension and explainedhow it can be diagnosed by excluding secondarycauses or lack of adherence. He also discussedthe management of resistant hypertension withhigh-dose drugs, including diuretics, calcium

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SSIF EDUCATIONAL EVENTS - PROGRAMME 2014

International Course on Echocardiographic Deformation Indexes

24-25 March - Milan, ItalyScientific organizers: C. Bussadori (Italy) and M. Carminati (Italy)

The aims of this live educational course are to provide participants with adequate theoretical and practicalinformation to allow an extensive use of these novel and advanced echocardiography methods, and to improvetheir ability to manage, in clinical practice, patients suffering from myocardial dysfunction of different origin,including myocardial ischemia, primary and secondary cardiomyopathy, and congenital heart diseases inchildren and adults.

2014 Asia-Pacific cardiovascular symposiumManaging cardiovascular risk factors to prevent the fatal end of cardiovascular continuum

1-2 March 2014 - Guangzhou, ChinaScientific organizers: L. Shuguang (China) and B. Tomlinson (China)

This symposium will examine recent evidence in the treatment of hypertension with a specific focus on thecorrect utilisation of the “old” drugs such as beta-blockers and the 'new' therapeutic approaches such asrenal denervation. Sessions will also be devoted to discussing emerging health problems in the Asia-Pacificarea and will offer possible solutions to the management of patients with hypertension complicated by otherrisk factors or related diseases.

antagonists, and beta blockers if hyperkinetic, and24-hour monitoring. Intervention is a newapproach to resistant hypertension according toA. Abu-Alfa (Lebanon). Preliminary results inselected cases demonstrateing the use of renaldenervation showed significant reduction in bloodpressure levels and in drug therapy. Further casesshowed that the use of implantable baroreflexstimulators can also improve hypertensioncontrol without major side effects.

The use of bioimaging in cardiovasculardiseases was discussed by E. Agabiti-Rosei (Italy)who presented the current techniques to evaluateatherosclerosis in the carotid artery, especiallythe plaque, by using ultrasound 3D reconstructionor MRI, to determine anatomical characteristics,and PET-CT to assess inflammation and theactivity of the wall deposit. The coronary arteriescan be studied in many ways, said M. Al-Mallah(Saudi Arabia), including SPECT perfusion withphysical or pharmacological stress to obtaininformation about the myocardial functionalreserve, CT or MRI scan to acquire anatomicaldetails and the calcification score of the vesselwall, and PET scan for metabolic evidence aboutheart activity under normal stimuli.

The panel focused on the problem of adherenceto treatment in cardiovascular diseases, whichappears to be very low in clinical practice. Manyproblems have to be faced, such as poor patientcollaboration, complexity of drug regimens,insufficient doctor communication, socioculturalobstacles, limited resources of healthcaresystems. Better strategies to measure adherenceand increase its rate are required to reducecardiovascular events.

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Copyright © Serono Symposia International Foundation, 2014. All rights reserved.

Editors: Francesca Cucciolla, Dorina Monaco, Michèle Piraux, Michael Withers

Contributor: Davide Mineo