European Heart Journal (2014) 35, 3315–3320 doi:10.1093/eurheartj/ehu423
Dan Atar: a new European Society of Cardiology Vice President Professor Dan Atar, MD, FESC, was inaugurated as a new Vice-President of the ESC during the ESC General Assembly on 2 September 2014 at the ESC Congress in Barcelona His research focuses on myocardial biomarkers, myocardial function, heart failure, and cardiovascular pharmacology. He has written .200 articles and book chapters and holds the fellowshiptitles FESC, FACC, and inaugural FAHA. The initial experience with the ESC was his Chairmanship of the ESC Working Group on Cardiovascular Pharmacotherapy in the years 2004–2006, as well as his repeated engagements at the CPC (Congress Program Committee). Dan Atar was also on a number of ESC guideline writing committees, amongst others the ‘2010 ESC Guideline on Atrial Fibrillation’ as well as the ‘2012 ESC Guideline Update on Atrial Fibrillation’ and the ‘2012 STEMI guideline’. In 2012, Dan Atar was elected Councillor and Board member of the ESC, and subsequently, Vice-President for the 2014–2016 term. ‘Please do not hesitate to contact me from the various National Societies if you have any ideas, suggestions or concerns regarding the collaboration between your country and the ESC’, he explains, before rushing on to his next scientific presentation. Dan Atar [email protected]. CardioPulse takes this opportunity to wish him good luck and much success in this exciting new position. Andros Tofield
The European Heart Academy One of Dr Panos Vardas’ visions for the European Society of Cardiology has been achieved, reports Dr Alec Vahanian The European Heart Academy is now one of the three divisions of the European Heart Agency of the European Society of Cardiology (ESC) besides advocacy, EU affairs, and the European Health Institute. The European Heart Academy is located in the ESC offices in Brussels and I have the pleasure of working in this active division with the outstanding productivity of Paulus Kirchhoff from Birmingham who acts as head of unit.
Panos E. Vardas Alec Vahanian In 2012 Panos Vardas said in his introductory talk ‘the ESC should be more academically-oriented through collaboration with universities, common projects with selected academic institutes and organize solid academic ESC entities such as the European Heart Academy’. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
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The future task of Dan Atar will be the responsibility for the National Societies. ‘I am very much looking forward to cultivate the mutual understanding and exchange between each of the National Societies and the ESC’, said Dan Atar and continued, ‘We must be aware of the fact that the National Societies are the backbones of the ESC. It is important to understand the needs and expectations of each of these societies towards their “mother”society, the ESC, such that, we at the Board as well as at the Heart House can deliver products and communications as tailored as possible’. In his daily assignment, Dan Atar holds a full Professorship in Cardiology at the University of Oslo, Norway, along with a Visiting Associate Professorship at the Johns Hopkins University, Baltimore, MD, USA. He also acts as Head of Research at Oslo University Hospital Ulleval, Dept. of Medicine, Oslo, Norway. Dan Atar trained in Denmark, Switzerland, and the USA before receiving his board certification in Internal Medicine and Cardiology in 1995.
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The goal of the ESC Academy is to create courses of a high scientific level leading to an accredited University diploma. Therefore, each course will be in partnership with a leading university to provide the academic accreditation. The aim here is to add on the existing ESC courses which provide CME. The first type of courses is those leading to Masters Degrees. The first course is the new executive-style Master of Science degree organized in collaboration with the London School of Economics (LSE), in particular with the help of Prof. Elias Mossialos. The course will provide a way to explore new options within the healthcare field such as management of clinics or hospitals, to occupy leading roles in regulatory assessment and evaluation agencies and, finally, play an advisory role in international and national organizations. The faculty will be leading cardiovascular specialists and leading health economists from the ESC and LSE.
PCHF-Group-Module 2
PCHF (2)
Frank Ruschitzka, Thomas Lu¨scher, Theresa McDonagh, John Cleland The ESC associations are invited to use the post-graduate course in heart failure as a template to run similar expert courses. Another course in this format is being considered by the EHRA to create an advance course in cardiac arrhythmia which could lead to either a Bologna certificate or a diploma of advanced study. The Maastricht University will deliver this diploma; the course will be located in Maastricht and also in different expert centres in Europe. Although this project is ambitious, it already exists and will no doubt complete in a harmonious way, the existing ESC courses. New courses will no doubt come and plans are already set for another Master of Science in translational medicine and a new unit is planned on the future of education. The final goal being to educate future leaders in cardiovascular medicine and help fill gaps in the further development of care for cardiovascular patients in Europe.
PCHF-Group-Module 3
PCHF (1)
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The course will be attended by cardiologists and cardiovascular professionals. The compulsory modules will include quality and outcome of cardiovascular science; economic analysis for health policy; systematic review and meta-analysis; economic evaluation in healthcare; cardiovascular epidemiology and prevention; masters dissertation. Three electives will include classes on topics such as principles of modern epidemiology; pharmaceutical economics and policies; measuring health system performance; financing healthcare; healthcare quality management; and statistical methods in healthcare economic evaluation. The course will include 2 weeks of intensive teaching courses at the London School of Economics and the ESC office in Brussels over a 2-year period. The intensive sessions will include a combination of academic lectures, seminars, individual meetings with faculty advisors, and revision sessions. Following the completion of course work participants will undertake a dissertation under the supervision of a member of LSE staff and there will be a 1-day examination. The first course will start in October 2015. It is expected that this course will provide cardiovascular specialists with the opportunity to acquire world-class knowledge in health economics, outcomes research, and management. It will also allow the next generation of leaders to broaden their horizons in an international environment. The second type of courses is expert courses leading to a diploma according to the Bologna agreement. The pioneering course is the post-graduate course in heart failure, the participants being young
cardiologists at the end of their training period with a strong interest in heart failure but also practicing heart failure specialists interested in widening their know-how and skills in the new areas of heart failure. The content provider is the Heart Failure Association of the ESC and an advisory board involving other ESC experts. The host university is the University of Zurich. The ESC Academy would play an important role in harmonizing the content, participating in the selection, and the evaluation of participants and encouraging joint efforts .The supporting structure is Zurich Heart House. The course is built into 12 modules, each module being composed of lectures, live cases, hands-on imaging, clinical rounds, and case-based learning during a 3-day period. This leads to an examination using MCQs and clinical cases. At the end the attendees will receive a certificate of advance study in heart failure of 10 ECTS according to the Bologna system and 300 h of education, including the self-study. The first 3 modules are already completed and comprehensive evaluation of the first modules showed that the participants felt that the quality of teaching was excellent.
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Master of Science in cardiovascular health economics launched by European Society of Cardiology and London School of Economics The executive-style MSc will provide world-class training in cardiovascular health economics and outcomes research to working cardiologists, scientists, and health economists
† † † † † †
economic analysis for health policy; quality and outcomes in cardiovascular sciences; economic evaluation in healthcare; systematic review and meta-analysis; cardiovascular epidemiology and prevention; and an MSc dissertation.
Students will choose two additional modules from a range of options that allow them to specialize in one or two areas of interest. Professor Kirchhof said: ‘Health economists may want to develop a specialization in cardiovascular health economics, while cardiologists could focus on a subspecialty of cardiovascular medicine such as prevention, arrhythmias, coronary artery disease, interventional cardiology or valvular heart disease’. Each student will be assigned a mentor from a senior member of the LSE or ESC faculty to help them meet their own aims for the course. Professor Kirchhof said: ‘We will try to cater for the specific needs of each person. It will be a small group of students and we expect a lot of lively interaction between teachers and students during the course. Students will be exposed to very interesting career models just by talking to their fellow classmates’. He concluded: ‘The ESC is the leading professional organization for cardiovascular medicine in Europe and probably the world and has a vast amount of expertise in postgraduate teaching. The LSE is
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A Master of Sciences (MSc) in Health Economics, Outcomes and Management in Cardiovascular Sciences has been launched by the European Heart Academy of the European Society of Cardiology (ESC) and the London School of Economics (LSE). It is the only health economics MSc focused on cardiovascular sciences. Professor Paulus Kirchhof, head of unit for university courses at the European Heart Academy and the ESC’s academic liaison for the MSc, said: ‘There is an increasing need to justify new therapies by demonstrating that they provide value for money. This concept has entered all areas of medicine because we have more therapies than society can provide’. He added: ‘Economic evaluation of medical intervention is increasingly shaping medical practice in Europe. The impact of economic considerations is rather prominent in cardiovascular diseases, due to their high morbidity and mortality, but also due to the chronic nature of most cardiovascular diseases. In addition, we have seen extremely successful (but also expensive) new treatments for patients suffering from cardiovascular diseases’. The executive-style MSc is aimed at cardiologists, scientists, and health economists looking to accelerate their careers or change focus. It aims to equip them with the health management, economics, research, and policy skills needed for advisory, management, or leadership roles in the field of cardiovascular disease. Graduates would be qualified to lead hospital departments, advise hospital chains, or plan health service provision. They may also be attractive employees for health insurance companies, or pharmaceutical and device companies. Scientists with the degree can develop an academic career in cardiovascular health outcomes and health economics. The course will accept a maximum of 30 participants for the first intake in October 2015. Applications can be submitted via the website of the London School of Economics (www.lse.ac.uk) from October 2014. Applications will be evaluated on a rolling basis by a dedicated committee until 30 candidates are selected. The expected course fees are £11 500 per year (£23 000 in total for the 2 years). The ESC is offering at least 15 stipends covering all tuition fees.
Applicants can indicate whether they want to be considered for a stipend when they apply for the course. Fully qualified cardiologists/biomedical scientists and health economists with a BSc or MSc are eligible for the course. Professor Kirchhof said: ‘A growing number of experienced cardiologists are noticing that the way they treat their patients or lead their units is influenced by economic considerations. Physicians increasingly find themselves in discussions with payers or those who represent them. We believe that training cardiologists in health economic evaluation will foster better communication with these stakeholders, and lead to the provision of better and more efficient care’. During the 2-year course students can continue their current work. Eight 2-week modules will be taught at the LSE in London and the European Heart Academy in Brussels during December and June of each year. There will also be online teaching and evaluation. The mandatory modules are:
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one of the most renowned institutions for health economic evaluation. Bringing these two bodies together to develop and deliver a Master of Sciences in Cardiovascular Health Economics has the potential to generate a course that will educate true leaders of the future. I expect that we will have many more applications than places’.
Following a full academic career in internal medicine, cardiology, pathophysiology, and basic and clinical research at the helm of the Department of Research at Basel University Hospitals and a number of other public academic functions, Professor Fritz Bu¨hler made the transition into a role in industry. It was 1990 when he made the switch to take up a clinical research leadership role at F. Hoffmann-La Roche Ltd after a connection with Basel University which had first begun in 1965. The move, he explained, was triggered by a desire to utilize his expertise in a new environment. ‘It was prompted by the fascination of integrating the experience gathered in internal medicine and cardiology, the broad translational research experience directing the Department of Research at the University of Basel with a challenging change to a new global role directing clinical research and development in the complexity of big pharma’, he said. At Roche, he led the organization’s world-wide clinical research and development and was also the Chief Medical Officer encompassing all aspects of strategic project portfolio management, financial, human resources, therapeutic-based operations, and department management. That saw a focus on novel aspects of developing medicines, with processes including modulation and simulation as well as the seeding of personalized medicine, a concept he has followed since 1972 when he published on personalized renin-related antihypertensive therapy with the beta-blocker propranolol.1 Professor Bu¨hler trained at the Medical Faculty in Basel and specialized in general internal medicine and focussed on cardiovascular disease. After a 4-year fellowship at Columbia University in New York in 1970 and a visiting professorship at Harvard University in 1977, he was appointed as the Chief Physician of Cardiology and later Head of the Department of Research of the Basel University Hospitals. During that time he founded the European Center of Pharmaceutical Medicine (ECPM), which he developed from 1990 to 2009. ‘The red thread of my academic career may be defined as translational medicine from genome and cell-based science to the clinical understanding of disease and development of medicines for therapy’, said Professor Bu¨hler. With a strong interest in high blood pressure research and treatment,2 the year 1987 saw a clear shift in the research/clinical
balance from 20/80 to 80/20, thereafter in favour of research. It was that factor which brought him to the greater attention of Roche and a major management role in private industry, but also saw him faced with the challenges of working in industry and the transition from a ‘free and safe life in academia’ to the ever-changing world of industry with big numbers of patients, collaborators, world-wide structure, and budget. ‘The greatest challenge was the transition from academic research, managing a department of some 200 people, to a global leadership role with enormous responsibility and a multiple of people and budgets all oriented towards development of successful medicines in the market’, he recalled. That involved learning the approach of industry, optimizing processes and structures, and reducing and prioritizing the medicines development portfolio as well as the strategic thinking involved in the next steps of Roche’s medicines development organization. He noted how the work in pharmaceutical medicines development was less related to individual patients but rather groups/cohorts of patients and the accompanying regulatory processes. However, while at Roche, he also recognized the importance of not losing patient contact and was grateful for the freedom to continue outpatient clinic activity at the Basel University Hospital, albeit limited to 1 day a month. What Professor Bu¨hler was able to bring to industry was a ‘broad understanding of internal and translational medicine in different therapeutic areas – from molecules of a medicine to personal use by patients’, though acknowledged that adapting to the new industry environment in an efficient, economical, and strategy-related way was not an easy process. After 5 years at Roche he decided to return to his academic and clinical roots. ‘There was a change in top management and in the process of the development of medicines which was different from my concepts, leadership and planning of the future. Due to this incompatibility I left Roche and developed a new life in clinical medicine postgraduate training as well as the founding of an early phase investment fund’, he said. That was firstly in Switzerland (Bank Julius Ba¨r) and subsequently in New York (Bear Stearns, now GP Morgan) after developing the belief
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Professor Fritz Bu¨hler, MD, has made the journey from academia and clinical work, into industry and back again. He reflects on his experiences with Mark Nicholls
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equipped Professor Bu¨hler with the insider expertise to bring new capacity as a consultant specializing in the interface between University and Pharmaceutical Industry including the Biotechnology Research Industry. This cooperation of 45 universities world-wide, a number of regulatory affairs specialists and 15 companies from the European Federation of Pharmaceutical Industries and Associations (EFPIA) resulted in a global interactive network, curriculum, and quality control standards which is now captured in the successor organization of the project, the PharmaTrain Federation, eventually to sustain programmes and standards in a new public –private partnership world-wide. That project came to an end for Professor Bu¨hler in April 2014 leaving him, at the age of 74, time ‘to relax, think about life, more reading and some writing and travelling’.
References 1. Buhler FR, Laragh JH, Baer L, Vaughan ED Jr, Brunner HR. Propranolol inhibition of renin secretion. A specific approach to diagnosis and treatment of renin-dependent hypertensive diseases. N Engl J Med 1972;287:1209 –1214. 2. Bu¨hler FR. Age and cardiovascular response adaptation: determinants of an antihypertensive treatment concept primarily based on betablockers and calcium entry blockers. Hypertension 1983;5(Suppl. 2):III94 – III100.
Scientific highlights from Heart Failure 2014 Heart failure hospitalization more than doubles in inflammatory bowel disease flares Previous studies have shown an association between chronic inflammatory diseases and an increased incidence of venous and arterial thrombotic disease. The present study investigated whether patients with inflammatory bowel disease (IBD), defined as Crohn’s disease and ulcerative colitis, had an increased risk of heart failure and whether this risk was correlated to periods of activity or ‘flares’ in the IBD. The researchers used a nationwide cohort of 5 436 647 Danish citizens aged 18 years and above with no history of IBD or heart failure. During 1997 to 2011, IBD developed in 23 681 patients, of whom 553 were hospitalized with heart failure during the follow-up. Rates of hospitalization for heart failure were compared between the IBD group and the remaining Danish population, adjusted for age and sex differences. In patients with new-onset IBD, disease activity (flare, persistent activity, remission) was monitored continuously throughout the study and determined by hospitalizations and prescriptions of glucocorticoids. Flares were defined as a prescription or hospitalization following a quiescent period. Persistent activity was defined as repeated prescriptions or hospitalizations. Patients with new-onset IBD had a 37% increased risk of hospitalization for heart failure during a mean follow-up of 6.4 years compared with the healthy population. When IBD patients had flares,
their risk of hospitalization for heart failure was 2.5 times greater, and it was 2.7 times greater during persistent activity. There was no increased risk during the quiescent stages of IBD. Dr Søren L. Kristensen, lead author, said: ‘Our findings suggest that efficient IBD treatment aimed at reducing the length and number of disease activity episodes might lower the risk of heart failure’.
Cardiovascular diseases increased during the Greek financial crisis Hospital admissions for cardiovascular diseases increased during the Greek financial crisis, according to two studies from Athens. The researchers retrospectively analysed all admissions to the cardiology department of Elpis General Hospital in Athens during 2003–2007 (pre-crisis period) and 2008 –2012 (crisis period). The researchers recorded admissions for acute myocardial infarction and atrial fibrillation (AF). They examined the results in younger patients and those without social insurance, and looked to see whether there were differences between men and women. The cardiology department received 3420 admissions during the pre-crisis period and 3860 admissions during the crisis period.
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that early phase investment into pharma-biotech companies could be done more efficiently with the full understanding of pharmaceutical research, development, and regulatory pathways, the understanding of financial processes and the market. Professor Bu¨hler said: ‘After Roche, I was offered similar positions in other pharmaceutical companies but I decided to use my industry experience in managing early phase investment funds and, in parallel, to develop new strategies in training of medicines development and regulation’. That saw the ECPM course become the European Center of Pharmaceutical Medicine with broader training programmes and new pharmaco-economic research. In 1996, the European Commission (EC) also invited him to participate in a team to conceptualize the Innovative Medicine Initiative (IMI), a private –public partnership programme with a budget of 2 billion Euros. ‘My contributions were not only for pharmaceutical research and medicines development in general but they became focussed on standardised training for medicines development, from molecule to marketplace’, he said. This vision led to another life change for him—from an advisory conceptualizing role for EC to create IMI to an almost opposite role, namely to conceive, apply, create, and coordinate universitybased complete modular training programmes in medicines development. Fifty years in academic medicine and research, including the 5 years in pharmaceutical industry research and drug development, had
3320 During the crisis period, the number of admissions for heart attacks rose in both sexes, but the finding was statistically significant only in women. Admissions also increased in people under the age of 45 years, but again the result was statistically significant only in women. The authors speculated that women’s protection from heart disease by oestrogen may have been cancelled by stress during the crisis. Atrial fibrillation admissions increased significantly in both sexes during the crisis, with an even greater rise in women. The climb in admissions was also seen in patients under 60 years old, with men being more susceptible. Admissions for AF doubled in patients (particularly women) with no social insurance while heart attack admissions increased in men and women without insurance, but the increase was statistically significant only in men. The authors believe that there were more patients without social insurance during the crisis which is why there were more admissions.
Researchers retrospectively examined medical records of 111 heart failure patients admitted to Tokyo Yamate Medical Center from 2011 to 2013. Study participants were followed up for 180 days after discharge. The study endpoint was readmission for heart failure, or cardiovascular-related death. For the analysis, patients were divided into those with heart failure with preserved ejection fraction (HFpEF) and those with heart failure with reduced ejection fraction (HFrEF). Of the 47 HFpEF patients, 15 reached the study endpoint during the follow-up. The only differences between patients who had events and those who did not were prescription of sleeping pills (benzodiazepine hypnotics), blood sodium levels at admission, and blood haemoglobin levels at discharge. Multivariate analysis showed that HFpEF patients who were prescribed sleeping pills were at eight times greater risk of rehospitalization for heart failure or cardiovascular-related death than HFpEF patients not prescribed these drugs [hazard ratio (HR) ¼ 8.063, P ¼ 0.010].
Sleeping problems are a frequent side effect of heart failure and patients are often prescribed sleeping pills on discharge from hospital.
Bivalirudin vs. heparin in planned percutaneous coronary intervention Researchers have found that a bivalirudin-based anticoagulation regimen increases the risk of myocardial infarction and stent thrombosis, but decreases the risk of bleeding, compared with a heparinbased regimen in patients undergoing percutaneous coronary intervention (PCI) for ischaemic heart disease. The meta-analysis pooled data from nearly 34 000 patients in 16 randomized, controlled trials that compared a bivalirudin-based with a heparin-based anticoagulation regimen on ischaemic and bleeding outcomes. In all, 2422 patients experienced a major adverse cardiac event (MACE). Treatment with a bivalirudin-based regimen led to a 9% relative increase in the risk of MACE compared with heparin-based regimens. This was primarily driven by increases in myocardial infarction and ischaemia-driven revascularization. There was no difference in the risk of death between the two treatment regimens. Bivalirudin substantially increased the risk of stent thrombosis overall. In patients with ST-segment elevation myocardial
infarction, bivalirudin increased the risk of acute stent thrombosis (risk ratio 4.27, 95% CI 2.28– 8.00; P , 0.0001) but not subacute stent thrombosis. A total of 1406 patients had a major bleed. Bivalirudin-based regimens lowered the risk of major bleeding, but the magnitude of the effect depended on concomitant glycoprotein IIb/ IIIa inhibitor (GPI) use. The reduction in bleeding occurred when a GPI was predominantly routinely used with heparin and only provisionally with bivalirudin; the benefit was attenuated when GPI use was provisional in both groups. The researchers concluded that physicians should weigh the trade-off between ischaemic and bleeding events when choosing between different anticoagulant regimens. The full article is at: http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(14)61216-2/abstract. Jennifer Taylor
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
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Sleeping pills increase cardiovascular events in heart failure patients
CardioPulse
Dan Atar: a new European Society of Cardiology Vice President Professor Dan Atar, MD, FESC, was inaugurated as a new Vice-President of the ESC during the ESC General Assembly on 2 September 2014 at the ESC Congress in Barcelona His research focuses on myocardial biomarkers, myocardial function, heart failure, and cardiovascular pharmacology. He has written .200 articles and book chapters and holds the fellowshiptitles FESC, FACC, and inaugural FAHA. The initial experience with the ESC was his Chairmanship of the ESC Working Group on Cardiovascular Pharmacotherapy in the years 2004–2006, as well as his repeated engagements at the CPC (Congress Program Committee). Dan Atar was also on a number of ESC guideline writing committees, amongst others the ‘2010 ESC Guideline on Atrial Fibrillation’ as well as the ‘2012 ESC Guideline Update on Atrial Fibrillation’ and the ‘2012 STEMI guideline’. In 2012, Dan Atar was elected Councillor and Board member of the ESC, and subsequently, Vice-President for the 2014–2016 term. ‘Please do not hesitate to contact me from the various National Societies if you have any ideas, suggestions or concerns regarding the collaboration between your country and the ESC’, he explains, before rushing on to his next scientific presentation. Dan Atar [email protected]. CardioPulse takes this opportunity to wish him good luck and much success in this exciting new position. Andros Tofield
The European Heart Academy One of Dr Panos Vardas’ visions for the European Society of Cardiology has been achieved, reports Dr Alec Vahanian The European Heart Academy is now one of the three divisions of the European Heart Agency of the European Society of Cardiology (ESC) besides advocacy, EU affairs, and the European Health Institute. The European Heart Academy is located in the ESC offices in Brussels and I have the pleasure of working in this active division with the outstanding productivity of Paulus Kirchhoff from Birmingham who acts as head of unit.
Panos E. Vardas Alec Vahanian In 2012 Panos Vardas said in his introductory talk ‘the ESC should be more academically-oriented through collaboration with universities, common projects with selected academic institutes and organize solid academic ESC entities such as the European Heart Academy’. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected].
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The future task of Dan Atar will be the responsibility for the National Societies. ‘I am very much looking forward to cultivate the mutual understanding and exchange between each of the National Societies and the ESC’, said Dan Atar and continued, ‘We must be aware of the fact that the National Societies are the backbones of the ESC. It is important to understand the needs and expectations of each of these societies towards their “mother”society, the ESC, such that, we at the Board as well as at the Heart House can deliver products and communications as tailored as possible’. In his daily assignment, Dan Atar holds a full Professorship in Cardiology at the University of Oslo, Norway, along with a Visiting Associate Professorship at the Johns Hopkins University, Baltimore, MD, USA. He also acts as Head of Research at Oslo University Hospital Ulleval, Dept. of Medicine, Oslo, Norway. Dan Atar trained in Denmark, Switzerland, and the USA before receiving his board certification in Internal Medicine and Cardiology in 1995.
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The goal of the ESC Academy is to create courses of a high scientific level leading to an accredited University diploma. Therefore, each course will be in partnership with a leading university to provide the academic accreditation. The aim here is to add on the existing ESC courses which provide CME. The first type of courses is those leading to Masters Degrees. The first course is the new executive-style Master of Science degree organized in collaboration with the London School of Economics (LSE), in particular with the help of Prof. Elias Mossialos. The course will provide a way to explore new options within the healthcare field such as management of clinics or hospitals, to occupy leading roles in regulatory assessment and evaluation agencies and, finally, play an advisory role in international and national organizations. The faculty will be leading cardiovascular specialists and leading health economists from the ESC and LSE.
PCHF-Group-Module 2
PCHF (2)
Frank Ruschitzka, Thomas Lu¨scher, Theresa McDonagh, John Cleland The ESC associations are invited to use the post-graduate course in heart failure as a template to run similar expert courses. Another course in this format is being considered by the EHRA to create an advance course in cardiac arrhythmia which could lead to either a Bologna certificate or a diploma of advanced study. The Maastricht University will deliver this diploma; the course will be located in Maastricht and also in different expert centres in Europe. Although this project is ambitious, it already exists and will no doubt complete in a harmonious way, the existing ESC courses. New courses will no doubt come and plans are already set for another Master of Science in translational medicine and a new unit is planned on the future of education. The final goal being to educate future leaders in cardiovascular medicine and help fill gaps in the further development of care for cardiovascular patients in Europe.
PCHF-Group-Module 3
PCHF (1)
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The course will be attended by cardiologists and cardiovascular professionals. The compulsory modules will include quality and outcome of cardiovascular science; economic analysis for health policy; systematic review and meta-analysis; economic evaluation in healthcare; cardiovascular epidemiology and prevention; masters dissertation. Three electives will include classes on topics such as principles of modern epidemiology; pharmaceutical economics and policies; measuring health system performance; financing healthcare; healthcare quality management; and statistical methods in healthcare economic evaluation. The course will include 2 weeks of intensive teaching courses at the London School of Economics and the ESC office in Brussels over a 2-year period. The intensive sessions will include a combination of academic lectures, seminars, individual meetings with faculty advisors, and revision sessions. Following the completion of course work participants will undertake a dissertation under the supervision of a member of LSE staff and there will be a 1-day examination. The first course will start in October 2015. It is expected that this course will provide cardiovascular specialists with the opportunity to acquire world-class knowledge in health economics, outcomes research, and management. It will also allow the next generation of leaders to broaden their horizons in an international environment. The second type of courses is expert courses leading to a diploma according to the Bologna agreement. The pioneering course is the post-graduate course in heart failure, the participants being young
cardiologists at the end of their training period with a strong interest in heart failure but also practicing heart failure specialists interested in widening their know-how and skills in the new areas of heart failure. The content provider is the Heart Failure Association of the ESC and an advisory board involving other ESC experts. The host university is the University of Zurich. The ESC Academy would play an important role in harmonizing the content, participating in the selection, and the evaluation of participants and encouraging joint efforts .The supporting structure is Zurich Heart House. The course is built into 12 modules, each module being composed of lectures, live cases, hands-on imaging, clinical rounds, and case-based learning during a 3-day period. This leads to an examination using MCQs and clinical cases. At the end the attendees will receive a certificate of advance study in heart failure of 10 ECTS according to the Bologna system and 300 h of education, including the self-study. The first 3 modules are already completed and comprehensive evaluation of the first modules showed that the participants felt that the quality of teaching was excellent.
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Master of Science in cardiovascular health economics launched by European Society of Cardiology and London School of Economics The executive-style MSc will provide world-class training in cardiovascular health economics and outcomes research to working cardiologists, scientists, and health economists
† † † † † †
economic analysis for health policy; quality and outcomes in cardiovascular sciences; economic evaluation in healthcare; systematic review and meta-analysis; cardiovascular epidemiology and prevention; and an MSc dissertation.
Students will choose two additional modules from a range of options that allow them to specialize in one or two areas of interest. Professor Kirchhof said: ‘Health economists may want to develop a specialization in cardiovascular health economics, while cardiologists could focus on a subspecialty of cardiovascular medicine such as prevention, arrhythmias, coronary artery disease, interventional cardiology or valvular heart disease’. Each student will be assigned a mentor from a senior member of the LSE or ESC faculty to help them meet their own aims for the course. Professor Kirchhof said: ‘We will try to cater for the specific needs of each person. It will be a small group of students and we expect a lot of lively interaction between teachers and students during the course. Students will be exposed to very interesting career models just by talking to their fellow classmates’. He concluded: ‘The ESC is the leading professional organization for cardiovascular medicine in Europe and probably the world and has a vast amount of expertise in postgraduate teaching. The LSE is
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A Master of Sciences (MSc) in Health Economics, Outcomes and Management in Cardiovascular Sciences has been launched by the European Heart Academy of the European Society of Cardiology (ESC) and the London School of Economics (LSE). It is the only health economics MSc focused on cardiovascular sciences. Professor Paulus Kirchhof, head of unit for university courses at the European Heart Academy and the ESC’s academic liaison for the MSc, said: ‘There is an increasing need to justify new therapies by demonstrating that they provide value for money. This concept has entered all areas of medicine because we have more therapies than society can provide’. He added: ‘Economic evaluation of medical intervention is increasingly shaping medical practice in Europe. The impact of economic considerations is rather prominent in cardiovascular diseases, due to their high morbidity and mortality, but also due to the chronic nature of most cardiovascular diseases. In addition, we have seen extremely successful (but also expensive) new treatments for patients suffering from cardiovascular diseases’. The executive-style MSc is aimed at cardiologists, scientists, and health economists looking to accelerate their careers or change focus. It aims to equip them with the health management, economics, research, and policy skills needed for advisory, management, or leadership roles in the field of cardiovascular disease. Graduates would be qualified to lead hospital departments, advise hospital chains, or plan health service provision. They may also be attractive employees for health insurance companies, or pharmaceutical and device companies. Scientists with the degree can develop an academic career in cardiovascular health outcomes and health economics. The course will accept a maximum of 30 participants for the first intake in October 2015. Applications can be submitted via the website of the London School of Economics (www.lse.ac.uk) from October 2014. Applications will be evaluated on a rolling basis by a dedicated committee until 30 candidates are selected. The expected course fees are £11 500 per year (£23 000 in total for the 2 years). The ESC is offering at least 15 stipends covering all tuition fees.
Applicants can indicate whether they want to be considered for a stipend when they apply for the course. Fully qualified cardiologists/biomedical scientists and health economists with a BSc or MSc are eligible for the course. Professor Kirchhof said: ‘A growing number of experienced cardiologists are noticing that the way they treat their patients or lead their units is influenced by economic considerations. Physicians increasingly find themselves in discussions with payers or those who represent them. We believe that training cardiologists in health economic evaluation will foster better communication with these stakeholders, and lead to the provision of better and more efficient care’. During the 2-year course students can continue their current work. Eight 2-week modules will be taught at the LSE in London and the European Heart Academy in Brussels during December and June of each year. There will also be online teaching and evaluation. The mandatory modules are:
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one of the most renowned institutions for health economic evaluation. Bringing these two bodies together to develop and deliver a Master of Sciences in Cardiovascular Health Economics has the potential to generate a course that will educate true leaders of the future. I expect that we will have many more applications than places’.
Following a full academic career in internal medicine, cardiology, pathophysiology, and basic and clinical research at the helm of the Department of Research at Basel University Hospitals and a number of other public academic functions, Professor Fritz Bu¨hler made the transition into a role in industry. It was 1990 when he made the switch to take up a clinical research leadership role at F. Hoffmann-La Roche Ltd after a connection with Basel University which had first begun in 1965. The move, he explained, was triggered by a desire to utilize his expertise in a new environment. ‘It was prompted by the fascination of integrating the experience gathered in internal medicine and cardiology, the broad translational research experience directing the Department of Research at the University of Basel with a challenging change to a new global role directing clinical research and development in the complexity of big pharma’, he said. At Roche, he led the organization’s world-wide clinical research and development and was also the Chief Medical Officer encompassing all aspects of strategic project portfolio management, financial, human resources, therapeutic-based operations, and department management. That saw a focus on novel aspects of developing medicines, with processes including modulation and simulation as well as the seeding of personalized medicine, a concept he has followed since 1972 when he published on personalized renin-related antihypertensive therapy with the beta-blocker propranolol.1 Professor Bu¨hler trained at the Medical Faculty in Basel and specialized in general internal medicine and focussed on cardiovascular disease. After a 4-year fellowship at Columbia University in New York in 1970 and a visiting professorship at Harvard University in 1977, he was appointed as the Chief Physician of Cardiology and later Head of the Department of Research of the Basel University Hospitals. During that time he founded the European Center of Pharmaceutical Medicine (ECPM), which he developed from 1990 to 2009. ‘The red thread of my academic career may be defined as translational medicine from genome and cell-based science to the clinical understanding of disease and development of medicines for therapy’, said Professor Bu¨hler. With a strong interest in high blood pressure research and treatment,2 the year 1987 saw a clear shift in the research/clinical
balance from 20/80 to 80/20, thereafter in favour of research. It was that factor which brought him to the greater attention of Roche and a major management role in private industry, but also saw him faced with the challenges of working in industry and the transition from a ‘free and safe life in academia’ to the ever-changing world of industry with big numbers of patients, collaborators, world-wide structure, and budget. ‘The greatest challenge was the transition from academic research, managing a department of some 200 people, to a global leadership role with enormous responsibility and a multiple of people and budgets all oriented towards development of successful medicines in the market’, he recalled. That involved learning the approach of industry, optimizing processes and structures, and reducing and prioritizing the medicines development portfolio as well as the strategic thinking involved in the next steps of Roche’s medicines development organization. He noted how the work in pharmaceutical medicines development was less related to individual patients but rather groups/cohorts of patients and the accompanying regulatory processes. However, while at Roche, he also recognized the importance of not losing patient contact and was grateful for the freedom to continue outpatient clinic activity at the Basel University Hospital, albeit limited to 1 day a month. What Professor Bu¨hler was able to bring to industry was a ‘broad understanding of internal and translational medicine in different therapeutic areas – from molecules of a medicine to personal use by patients’, though acknowledged that adapting to the new industry environment in an efficient, economical, and strategy-related way was not an easy process. After 5 years at Roche he decided to return to his academic and clinical roots. ‘There was a change in top management and in the process of the development of medicines which was different from my concepts, leadership and planning of the future. Due to this incompatibility I left Roche and developed a new life in clinical medicine postgraduate training as well as the founding of an early phase investment fund’, he said. That was firstly in Switzerland (Bank Julius Ba¨r) and subsequently in New York (Bear Stearns, now GP Morgan) after developing the belief
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Professor Fritz Bu¨hler, MD, has made the journey from academia and clinical work, into industry and back again. He reflects on his experiences with Mark Nicholls
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equipped Professor Bu¨hler with the insider expertise to bring new capacity as a consultant specializing in the interface between University and Pharmaceutical Industry including the Biotechnology Research Industry. This cooperation of 45 universities world-wide, a number of regulatory affairs specialists and 15 companies from the European Federation of Pharmaceutical Industries and Associations (EFPIA) resulted in a global interactive network, curriculum, and quality control standards which is now captured in the successor organization of the project, the PharmaTrain Federation, eventually to sustain programmes and standards in a new public –private partnership world-wide. That project came to an end for Professor Bu¨hler in April 2014 leaving him, at the age of 74, time ‘to relax, think about life, more reading and some writing and travelling’.
References 1. Buhler FR, Laragh JH, Baer L, Vaughan ED Jr, Brunner HR. Propranolol inhibition of renin secretion. A specific approach to diagnosis and treatment of renin-dependent hypertensive diseases. N Engl J Med 1972;287:1209 –1214. 2. Bu¨hler FR. Age and cardiovascular response adaptation: determinants of an antihypertensive treatment concept primarily based on betablockers and calcium entry blockers. Hypertension 1983;5(Suppl. 2):III94 – III100.
Scientific highlights from Heart Failure 2014 Heart failure hospitalization more than doubles in inflammatory bowel disease flares Previous studies have shown an association between chronic inflammatory diseases and an increased incidence of venous and arterial thrombotic disease. The present study investigated whether patients with inflammatory bowel disease (IBD), defined as Crohn’s disease and ulcerative colitis, had an increased risk of heart failure and whether this risk was correlated to periods of activity or ‘flares’ in the IBD. The researchers used a nationwide cohort of 5 436 647 Danish citizens aged 18 years and above with no history of IBD or heart failure. During 1997 to 2011, IBD developed in 23 681 patients, of whom 553 were hospitalized with heart failure during the follow-up. Rates of hospitalization for heart failure were compared between the IBD group and the remaining Danish population, adjusted for age and sex differences. In patients with new-onset IBD, disease activity (flare, persistent activity, remission) was monitored continuously throughout the study and determined by hospitalizations and prescriptions of glucocorticoids. Flares were defined as a prescription or hospitalization following a quiescent period. Persistent activity was defined as repeated prescriptions or hospitalizations. Patients with new-onset IBD had a 37% increased risk of hospitalization for heart failure during a mean follow-up of 6.4 years compared with the healthy population. When IBD patients had flares,
their risk of hospitalization for heart failure was 2.5 times greater, and it was 2.7 times greater during persistent activity. There was no increased risk during the quiescent stages of IBD. Dr Søren L. Kristensen, lead author, said: ‘Our findings suggest that efficient IBD treatment aimed at reducing the length and number of disease activity episodes might lower the risk of heart failure’.
Cardiovascular diseases increased during the Greek financial crisis Hospital admissions for cardiovascular diseases increased during the Greek financial crisis, according to two studies from Athens. The researchers retrospectively analysed all admissions to the cardiology department of Elpis General Hospital in Athens during 2003–2007 (pre-crisis period) and 2008 –2012 (crisis period). The researchers recorded admissions for acute myocardial infarction and atrial fibrillation (AF). They examined the results in younger patients and those without social insurance, and looked to see whether there were differences between men and women. The cardiology department received 3420 admissions during the pre-crisis period and 3860 admissions during the crisis period.
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that early phase investment into pharma-biotech companies could be done more efficiently with the full understanding of pharmaceutical research, development, and regulatory pathways, the understanding of financial processes and the market. Professor Bu¨hler said: ‘After Roche, I was offered similar positions in other pharmaceutical companies but I decided to use my industry experience in managing early phase investment funds and, in parallel, to develop new strategies in training of medicines development and regulation’. That saw the ECPM course become the European Center of Pharmaceutical Medicine with broader training programmes and new pharmaco-economic research. In 1996, the European Commission (EC) also invited him to participate in a team to conceptualize the Innovative Medicine Initiative (IMI), a private –public partnership programme with a budget of 2 billion Euros. ‘My contributions were not only for pharmaceutical research and medicines development in general but they became focussed on standardised training for medicines development, from molecule to marketplace’, he said. This vision led to another life change for him—from an advisory conceptualizing role for EC to create IMI to an almost opposite role, namely to conceive, apply, create, and coordinate universitybased complete modular training programmes in medicines development. Fifty years in academic medicine and research, including the 5 years in pharmaceutical industry research and drug development, had
3320 During the crisis period, the number of admissions for heart attacks rose in both sexes, but the finding was statistically significant only in women. Admissions also increased in people under the age of 45 years, but again the result was statistically significant only in women. The authors speculated that women’s protection from heart disease by oestrogen may have been cancelled by stress during the crisis. Atrial fibrillation admissions increased significantly in both sexes during the crisis, with an even greater rise in women. The climb in admissions was also seen in patients under 60 years old, with men being more susceptible. Admissions for AF doubled in patients (particularly women) with no social insurance while heart attack admissions increased in men and women without insurance, but the increase was statistically significant only in men. The authors believe that there were more patients without social insurance during the crisis which is why there were more admissions.
Researchers retrospectively examined medical records of 111 heart failure patients admitted to Tokyo Yamate Medical Center from 2011 to 2013. Study participants were followed up for 180 days after discharge. The study endpoint was readmission for heart failure, or cardiovascular-related death. For the analysis, patients were divided into those with heart failure with preserved ejection fraction (HFpEF) and those with heart failure with reduced ejection fraction (HFrEF). Of the 47 HFpEF patients, 15 reached the study endpoint during the follow-up. The only differences between patients who had events and those who did not were prescription of sleeping pills (benzodiazepine hypnotics), blood sodium levels at admission, and blood haemoglobin levels at discharge. Multivariate analysis showed that HFpEF patients who were prescribed sleeping pills were at eight times greater risk of rehospitalization for heart failure or cardiovascular-related death than HFpEF patients not prescribed these drugs [hazard ratio (HR) ¼ 8.063, P ¼ 0.010].
Sleeping problems are a frequent side effect of heart failure and patients are often prescribed sleeping pills on discharge from hospital.
Bivalirudin vs. heparin in planned percutaneous coronary intervention Researchers have found that a bivalirudin-based anticoagulation regimen increases the risk of myocardial infarction and stent thrombosis, but decreases the risk of bleeding, compared with a heparinbased regimen in patients undergoing percutaneous coronary intervention (PCI) for ischaemic heart disease. The meta-analysis pooled data from nearly 34 000 patients in 16 randomized, controlled trials that compared a bivalirudin-based with a heparin-based anticoagulation regimen on ischaemic and bleeding outcomes. In all, 2422 patients experienced a major adverse cardiac event (MACE). Treatment with a bivalirudin-based regimen led to a 9% relative increase in the risk of MACE compared with heparin-based regimens. This was primarily driven by increases in myocardial infarction and ischaemia-driven revascularization. There was no difference in the risk of death between the two treatment regimens. Bivalirudin substantially increased the risk of stent thrombosis overall. In patients with ST-segment elevation myocardial
infarction, bivalirudin increased the risk of acute stent thrombosis (risk ratio 4.27, 95% CI 2.28– 8.00; P , 0.0001) but not subacute stent thrombosis. A total of 1406 patients had a major bleed. Bivalirudin-based regimens lowered the risk of major bleeding, but the magnitude of the effect depended on concomitant glycoprotein IIb/ IIIa inhibitor (GPI) use. The reduction in bleeding occurred when a GPI was predominantly routinely used with heparin and only provisionally with bivalirudin; the benefit was attenuated when GPI use was provisional in both groups. The researchers concluded that physicians should weigh the trade-off between ischaemic and bleeding events when choosing between different anticoagulant regimens. The full article is at: http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(14)61216-2/abstract. Jennifer Taylor
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Sleeping pills increase cardiovascular events in heart failure patients
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