Cardiology on the cutting edge: updates from the European Society of Cardiology (ESC) Congress 2020

The 2020 annual Congress of the European Society of Cardiology (ESC) was the first ever to be held virtually. Under the spotlight of ‘the cutting edge of cardiology’, exciting and ground-breaking cardiovascular (CV) science was presented both in basic and clinical research. This commentary summarizes essential updates from ESC 2020—The Digital Experience. Despite the challenges that coronavirus disease 2019 (COVID-19) has posed on the conduct of clinical trials, the ESC Congress launched the results of major studies bringing innovation to the field of general cardiology, cardiac surgery, heart failure, interventional cardiology, and atrial fibrillation. In addition to three new ESC guidelines updates, the first ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease were presented. As former ESC president, Professor Casadei undoubtedly pointed out the ESC Congress 2020 was a great success. During the ESC 2020 Congress, BMC Cardiovascular Disorders updated to seven journal sections including Arrhythmias and Electrophysiology, CV Surgery, Coronary Artery Disease, Epidemiology and Digital health, Hypertension and Vascular biology, Primary prevention and CV Risk, and Structural Diseases, Heart Failure, and Congenital Disorders. To conclude, an important take-home message for all CV health care professionals engaged in the COVID-19 pandemic is that we must foresee and be prepared to tackle the dramatic, long-term CV complications of COVID-19 patients.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic dramatically changed the world and way of living. Nevertheless, the 2020 European Society of Cardiology (ESC) annual Congress remained immune, from a scientific point of view, becoming an event like no other, with the most exciting ground-breaking scientific presentations covering the full spectrum of cardiovascular (CV) medicine. The spotlight theme of this virtual ESC Congress was 'the cutting edge of cardiology' and it gathered a record-breaking audience of 116,000 delegates from 211 countries [1].
Although daily life has been significantly affected by the pandemic, 'cardiovascular diseases are still the number one killer worldwide and that as a community we continue to make great strides to improve the lives of our patients' [1]. The relevance of such a statement is of utmost importance now more than ever, since we failed to foresee the direct and indirect CV consequences of COVID-19 in our patients [2]. Indeed, the fear of COVID-19 strikingly reduced hospital admissions due to both acute coronary syndrome (ACS) and heart failure (HF) up to 50% [3][4][5][6]. This in turn, has dramatic Open Access *Correspondence: enrique.gce@gmail.com 1 Cardiology Department, Barzilai University Medical Center, Hahistadrout St 2, 30604 Ashkelon, Israel Full list of author information is available at the end of the article consequences for long-term ACS complications and is already associated with increased mortality for both ischemic heart disease and decompensated HF [4,6]. Therefore, it is important that we prepare for the consequences of the pandemic and thoroughly consider the treatment of CV diseases in the new dimension provided by COVID-19 along while keeping the pace with CV research [7].
Despite being virtual, the Congress attracted a great deal of excellent science, with expected impact on the clinical practice for both cardiologists and non-cardiologists. The ESC Congress shed light on the results of breakthrough studies bringing innovation to the field of cardiology in addition to four new guidelines presented, i.e. those for the management of (1) atrial fibrillation (AF) [8], (2) acute coronary syndromes in patients presenting without persistent ST-segment elevation [9], (3) adult congenital heart diseases [10], and (4) on sports cardiology and exercise in patients with CV disease [11].
In this commentary, we summarized the most important trials presented during the 2020 Virtual ESC Congress (Table 1) which we predict will improve our everyday clinical practice [12][13][14][15][16][17][18][19][20][21][22][23][24]. The EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) trial [23] further strengthened the positive findings observed in the DAPA-HF (Study to Evaluate the Effect of Dapagliflozin on the Incidence of Worsening Heart Failure or Cardiovascular Death in Patients With Chronic Heart Failure) trial [25]. In this study, the antidiabetic drug empagliflozin on top of optimized medical therapy reduced the composite primary endpoint of CV death and hospitalization in patients with HF and reduced ejection fraction (HFrEF), with the great majority of them presenting with a left ventricle ejection fraction (LVEF) of ≤ 30%. In addition, empagliflozin showed positive effects on reducing the progression of kidney disease [23]. A meta-analysis of EMPEROR-Reduced and DAPA-HF trials confirmed these findings [26].
With regard to inflammation and CV disease, the LoDoCo2 (Low Dose Colchicine for secondary prevention of cardiovascular disease) trial showed that in patients with chronic coronary disease, low-dose colchicine (0.5 mg once daily) significantly reduced the risk of CV events compared with placebo [21]. These results confirmed the previous observations from the open-label LoDoCo (Low Dose Colchicine) trial, that found a reduced risk of acute CV events among those patients with chronic coronary disease who received 0.5 mg of colchicine once daily than the placebo group [27]. These beneficial effects were first observed in the COLCOT (Colchicine Cardiovascular Outcomes Trial), where patients with a recent acute myocardial infarction (within 30 days) who received colchicine 0.5 mg once daily experienced less frequently the composite endpoint of CV death, resuscitated cardiac arrest, myocardial infarction, stroke, or urgent hospitalization for angina leading to coronary revascularization compared with those who received placebo [28].
Interesting news came from the AF field, not only due to the publication of the updated guidelines [8], but also from the results of three major studies-the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial), RATE-AF (Rate Control Therapy Evaluation in Permanent Atrial Fibrillation), and CASA-AF (Catheter Ablation Versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation) [29]. The EAST-AFNET 4 found that the early initiation of a rhythm control therapy was associated with a reduced risk of CV outcomes (death from CV causes, stroke, hospitalization for HF, or ACS) than usual care in those patients with early AF and other CV diseases across a 5-year follow-up period [20]. The RATE-AF trial gave a new life to an old, sometimes neglected, drug like digoxin. Indeed, this study showed that digoxin was associated with symptom improvement and reduction in N-terminal-pro B-type natriuretic peptide compared with a β-blocker in patients with permanent AF [12]. CASA-AF demonstrated that surgical ablation was not superior to catheter ablation in treating long-standing persistent AF, while catheter ablation allowed greater symptomatic relief, cost-effectiveness, and quality of life [29].
A relevant trial in these challenging times of COVID-19 was presented at the ESC Congress, the BRACE CORONA (Angiotensin Receptor Blockers and Angiotensin-converting Enzyme Inhibitors and Adverse Outcomes in Patients With COVID19) trial. This study tested the temporary suspension of renin-angiotensinaldosterone system (RAAS) blockers for 30 days versus continuation of these drugs in those chronically taking RAAS blockers and hospitalized due to COVID-19 [13]. The conclusion of the study was that among patients hospitalized with COVID-19 and receiving chronic a RAAS blocker, drug suspension was not beneficial and suspension versus continuation did not improve the days alive and out of the hospital [13].
Lastly, a game changing new molecule, mavacamten, a selective allosteric inhibitor of cardiac myosin ATPase, improved exercise capacity, left ventricular outflow tract obstruction, New York Heart Association (NYHA) functional class, and health status in patients with obstructive hypertrophic cardiomyopathy. The results of the EXPLORER-HCM trial might reshape, in the future, the landscape of hypertrophic cardiomyopathy, significantly reducing the number of patients with Randomized, parallel, controlled trial Patients with long-standing persistent AF 120 patients 80 assigned to surgical ablation 60 assigned to catheter ablation No group differences on primary outcomes observed at 12 months-freedom from AF, AF burden or serious adverse effects. One death in surgical group. Improved symptomatic relief, cost-effectiveness, and quality of life in catheter group the obstructive form of the disease and, perhaps, ameliorating long-term outcomes and reducing the risk of sudden death in these patients [22]. During the 2020 Virtual ESC Congress, the Editorial Board of BMC Cardiovascular Disorders met. This virtual meeting was led by the Editor, Dr. Ciarán Martin Fitzpatrick, together with Sections Editors and most Associate Editors. The meeting provided the opportunity to discuss the positive changes at the Journal and the future steps to keep progressing. The improvement in the handling of manuscripts by Associate Editors greatly reduced turnaround times and attracted more submissions in the past months. As far as the metrics is concerned, BMC Cardiovascular Disorders steadily improved from previous years with an updated 2019 yearly downloads of 890,588 and impact factor of 2.078. The Journal has also updated its sections to comply with new relevant topics in CV medicine. The new sections are: Arrhythmias and Electrophysiology; CV Surgery; Coronary Artery Disease; Epidemiology and Digital Health; Hypertension and Vascular Biology; Primary Prevention and CV Risk, and Structural Diseases, Heart Failure, and Congenital Disorders. Presented during this meeting was Lesyuk et al.'s 'Cost-of-illness studies in heart failure: a systematic review 2004-2016' [30], which was the journal's most cited article so far in 2020 with 37 citations.
Together with this exciting news, BMC Cardiovascular is pleased to offer its readers a wide range of submission initiatives, which are helpful in the progression of knowledge within the CV field. We must bear in mind that despite the world locking down momentarily, the continuous effort of healthcare professionals and researchers contributed to timely treatments and a better understanding of the COVID-19 disease and its direct and indirect impact on patients' management, treatment, outcomes and, ultimately, our daily life.