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AMSTERDAM – When the European Society of Cardiology in June reset its target systolic blood pressure for patients with diabetes, chronic kidney disease, or a history of cardiovascular disease to less than 140 mm Hg, it joined a small but growing cadre of medical societies that have looked at recent evidence and concluded that nothing currently justifies treating to a target systolic blood pressure below 130 mm Hg or to a diastolic pressure below 80 mm Hg.
The European Society of Cardiology’s new edition of hypertension management guidelines, produced in collaboration with the European Society of Hypertension, contrasts with the conspicuous void in U.S. practice that’s been widely acknowledged for a few years now: the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the prevailing version of U.S. hypertension-management guidelines, is a decade old and outdated.
The delay-plagued process to come out with the eighth JNC edition (JNC 8) took an unexpected turn last June, when the National Heart, Lung, and Blood Institute, the agency that shepherded the first seven editions of U.S. hypertension guidelines going back to 1976, announced that it was immediately turning responsibility for getting JNC 8 finalized and out to the public over to "partner organizations" such as the American College of Cardiology and American Heart Association.
With this new wrinkle, even with the ACC and AHA scrambling to deal with their new responsibility, it seems like JNC 8 – or whatever name it will have when it finally emerges – will not come out until 2014 at the soonest, making the ESC guidelines the only up-to-date hypertension recommendations from a cardiology-oriented medical group for at least several more months.
A U.S. view of the Euro guidelines
"U.S. physicians need to be aware of the evidence as it evolves," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill, and a member of the panel that’s been writing JNC 8.
"The American Diabetes Association came out with a similar recommendation" on the systolic blood pressure target for patients with diabetes. U.S. physicians should "see what the ADA says, see what the ESC says, and then decide what they should do. They need to read the recommendations and supporting evidence and see if it applies to their patients," Dr. Smith advised in an interview. "I think that patients and physicians will look at the current evidence and respond. You’ve got to go with what the evidence says and what seems best for the patient. No law says that you shall only do what is in the" JNC 7 guidelines.
A trickier situation may be settings in which physicians are assessed based on how many of their patients with diabetes reach a blood pressure target of less than 130/80, he said. "How do health care systems respond to evidence as it evolves? At what point should performance measures get changed?" Dr. Smith asked.
But because of its orientation to European populations, the new ESC hypertension guidelines can’t completely fill the U.S. vacuum.
"I’m sure JNC 8 will be nuanced differently than the European guidelines because we have a different population in the U.S., particularly African Americans and more patients with renal failure," said Dr. Kim Allan Williams Sr. of Wayne State University, Detroit. Dr. Williams will take the position of professor of medicine and chief of cardiovascular services at Rush University Medical Center in Chicago on Nov. 1. "As a practitioner, I would worry about using 140/90 mm Hg as the only target for the African American population that I deal with all the time. The stroke and renal failure rates are much higher in these patients" than in other patients with hypertension, he said in an interview. "The new European guidelines don’t deal with patients with African ancestry. JNC 7 had a section on blood pressure management in minority groups, which was very helpful."
Resetting the target for diabetics
The dialing up of the target systolic blood pressure for patients with diabetes or other high-risk factors, and the resulting damping down of antihypertensive treatment intensity, is the biggest change in the 2013 ESC hypertension recommendations, said Dr. Giuseppe Mancia, who chaired the task force that wrote the recommendations.
"We need to base the recommendations on the evidence. It’s been a consistent finding, in ONTARGET, ACCORD, and in other studies, that pushing the blood pressure of patients with diabetes below 130 mm Hg provided no additional benefit but was linked with more adverse events. If you set a lower target you need to be absolutely sure there is no harm associated with it, and at the moment we cannot say that.
"Adverse events [leads to] more discontinuation of treatment, and there is now evidence that discontinuation is closely related to an increase in events," said Dr. Mancia, professor of medicine at the University of Milan and cochair of the ESC hypertension task force. "There is a remarkable relationship between longer time taking antihypertensive drugs and cardiovascular protection."
"We were probably too radical in the previous guidelines" in setting a target systolic pressure at less than 130 mm Hg, said Dr. Renata Cífková, professor and head of preventive cardiology at Thomayer Teaching Hospital in Prague and a member of the ESC hypertension panel. "We saw that this was not evidence based. When we reviewed the same studies and also included the newer studies, like ACCORD, it basically confirmed our new blood pressure targets." Another advantage is that patients and physicians "will feel more comfortable with these goals," both in their achievability and by producing fewer adverse events," she said in an interview.
"This is the first major change in the hypertension guidelines for a number of years," the first full update since 2007, said Dr. Bryan Williams, professor and chairman of medicine at University College, London. "The data presented showed that, while there is indisputable evidence to lower pressures below 150/90 mm Hg, and strong evidence to lower below 140/90 mm Hg, there is limited or no evidence to recommend lowering pressures to below 130/80 mm Hg, and in some situations there is evidence for a signal of harm," said Dr. Williams. "The new guidelines simplify the target, a blood pressure of less than 140 mm Hg for everyone, regardless of their level of risk."
"The change in target means that ‘the lower the better’ is no longer true. This will reduce the number of drugs that patients receive and will avoid some adverse effects," said Dr. Nikolaus Marx, professor and director of medicine at Aachen (Germany) University Hospital.
Other groups came first
As Dr. Smith noted, the ESC is not the first medical group to scale back aggressive blood pressure targets for patients with diabetes or chronic kidney disease, but it may be the first major cardiology society to do so. Last year, the Kidney Disease Improving Global Outcomes foundation issued guidelines for hypertension management in patients with chronic kidney disease (Kidney International Supplement 2012;2:340-414). The expert panel recommended a target pressure of 140/90 mm Hg or below for patients with chronic kidney disease with or without diabetes as long as their daily urine albumin remained below 30 mg. For patients with more severe albuminuria, the panel recommended a target of 130/80 mm Hg or less for all chronic kidney disease patients regardless of their diabetes status.
Earlier this year, the American Diabetes Association published its Standards of Medical Care in Diabetes–2013, which set a target blood pressure for patients with diabetes at less than 140/80 mm Hg (the ESC set a diastolic pressure target of less than 85 mm Hg) (Diabetes Care 2013;36:S11-S66).
Other changes in the ESC guidelines
The ESC guidelines include some other notable changes (Euro. Heart J. 2013;34:2159-219):
• The basic systolic blood pressure goal for elderly patients, defined as 65 years or older, was set as less than 150 mm Hg. The goal can lower to less than 140 mm Hg for "fit elderly patients" younger than 80 years old if treatment is well tolerated.
• The guidelines place new emphasis on using some method for out-of-office blood pressure measurement – either ambulatory or home-based blood pressure measurement – for patients suspected of having either false-positive office-based blood pressure measurements (white coat hypertension) or false-negative office blood pressure levels (masked hypertension).
• The universe of first-line antihypertensive medications was whittled down to four: thiazide diuretics, calcium channel blockers, ACE inhibitors, and angiotensin-receptor blockers. Although the new guidelines call beta-blockers a "cornerstone" of treatment for patients with coronary heart disease and tachyarrhythmias, including atrial fibrillation, they are no longer seen as first-line agents for patients without these coexisting cardiac diseases or for young patients.
• A section on treating hypertension in young adults encourages applying the below 140/90 mm Hg target to these patients as well after a reasonable attempt at lifestyle intervention only.
• An updated approach to managing gestational hypertension and preventing preeclampsia includes use of prophylactic aspirin by women at moderate or high risk of preeclampsia, and treating pregnant women to a blood pressure of less than 150/95 mm Hg if pressure this high is persistent, or to a target of less than 140/90 mm Hg in women with gestational hypertension, symptoms, or subclinical organ damage.
Dr. Smith and Dr. Williams said that they had no relevant disclosures. Dr. Mancia said that he has been a consultant to 14 drug and device companies. Dr. Renata Cífková said that she had been a consultant to Daiichi Sankyo, Teva, Zentiva, Merck Sharpe and Dohme, Actavis, Berlin Chemie, Boehringer Ingelheim, and Bayer. Dr. Marx said that he has been a consultant to 13 drug and device companies. Dr. Williams said that he has been a consultant to Pfizer, Merck, Sanofi-BMS, and Novartis.
On Twitter @mitchelzoler
AMSTERDAM – When the European Society of Cardiology in June reset its target systolic blood pressure for patients with diabetes, chronic kidney disease, or a history of cardiovascular disease to less than 140 mm Hg, it joined a small but growing cadre of medical societies that have looked at recent evidence and concluded that nothing currently justifies treating to a target systolic blood pressure below 130 mm Hg or to a diastolic pressure below 80 mm Hg.
The European Society of Cardiology’s new edition of hypertension management guidelines, produced in collaboration with the European Society of Hypertension, contrasts with the conspicuous void in U.S. practice that’s been widely acknowledged for a few years now: the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the prevailing version of U.S. hypertension-management guidelines, is a decade old and outdated.
The delay-plagued process to come out with the eighth JNC edition (JNC 8) took an unexpected turn last June, when the National Heart, Lung, and Blood Institute, the agency that shepherded the first seven editions of U.S. hypertension guidelines going back to 1976, announced that it was immediately turning responsibility for getting JNC 8 finalized and out to the public over to "partner organizations" such as the American College of Cardiology and American Heart Association.
With this new wrinkle, even with the ACC and AHA scrambling to deal with their new responsibility, it seems like JNC 8 – or whatever name it will have when it finally emerges – will not come out until 2014 at the soonest, making the ESC guidelines the only up-to-date hypertension recommendations from a cardiology-oriented medical group for at least several more months.
A U.S. view of the Euro guidelines
"U.S. physicians need to be aware of the evidence as it evolves," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill, and a member of the panel that’s been writing JNC 8.
"The American Diabetes Association came out with a similar recommendation" on the systolic blood pressure target for patients with diabetes. U.S. physicians should "see what the ADA says, see what the ESC says, and then decide what they should do. They need to read the recommendations and supporting evidence and see if it applies to their patients," Dr. Smith advised in an interview. "I think that patients and physicians will look at the current evidence and respond. You’ve got to go with what the evidence says and what seems best for the patient. No law says that you shall only do what is in the" JNC 7 guidelines.
A trickier situation may be settings in which physicians are assessed based on how many of their patients with diabetes reach a blood pressure target of less than 130/80, he said. "How do health care systems respond to evidence as it evolves? At what point should performance measures get changed?" Dr. Smith asked.
But because of its orientation to European populations, the new ESC hypertension guidelines can’t completely fill the U.S. vacuum.
"I’m sure JNC 8 will be nuanced differently than the European guidelines because we have a different population in the U.S., particularly African Americans and more patients with renal failure," said Dr. Kim Allan Williams Sr. of Wayne State University, Detroit. Dr. Williams will take the position of professor of medicine and chief of cardiovascular services at Rush University Medical Center in Chicago on Nov. 1. "As a practitioner, I would worry about using 140/90 mm Hg as the only target for the African American population that I deal with all the time. The stroke and renal failure rates are much higher in these patients" than in other patients with hypertension, he said in an interview. "The new European guidelines don’t deal with patients with African ancestry. JNC 7 had a section on blood pressure management in minority groups, which was very helpful."
Resetting the target for diabetics
The dialing up of the target systolic blood pressure for patients with diabetes or other high-risk factors, and the resulting damping down of antihypertensive treatment intensity, is the biggest change in the 2013 ESC hypertension recommendations, said Dr. Giuseppe Mancia, who chaired the task force that wrote the recommendations.
"We need to base the recommendations on the evidence. It’s been a consistent finding, in ONTARGET, ACCORD, and in other studies, that pushing the blood pressure of patients with diabetes below 130 mm Hg provided no additional benefit but was linked with more adverse events. If you set a lower target you need to be absolutely sure there is no harm associated with it, and at the moment we cannot say that.
"Adverse events [leads to] more discontinuation of treatment, and there is now evidence that discontinuation is closely related to an increase in events," said Dr. Mancia, professor of medicine at the University of Milan and cochair of the ESC hypertension task force. "There is a remarkable relationship between longer time taking antihypertensive drugs and cardiovascular protection."
"We were probably too radical in the previous guidelines" in setting a target systolic pressure at less than 130 mm Hg, said Dr. Renata Cífková, professor and head of preventive cardiology at Thomayer Teaching Hospital in Prague and a member of the ESC hypertension panel. "We saw that this was not evidence based. When we reviewed the same studies and also included the newer studies, like ACCORD, it basically confirmed our new blood pressure targets." Another advantage is that patients and physicians "will feel more comfortable with these goals," both in their achievability and by producing fewer adverse events," she said in an interview.
"This is the first major change in the hypertension guidelines for a number of years," the first full update since 2007, said Dr. Bryan Williams, professor and chairman of medicine at University College, London. "The data presented showed that, while there is indisputable evidence to lower pressures below 150/90 mm Hg, and strong evidence to lower below 140/90 mm Hg, there is limited or no evidence to recommend lowering pressures to below 130/80 mm Hg, and in some situations there is evidence for a signal of harm," said Dr. Williams. "The new guidelines simplify the target, a blood pressure of less than 140 mm Hg for everyone, regardless of their level of risk."
"The change in target means that ‘the lower the better’ is no longer true. This will reduce the number of drugs that patients receive and will avoid some adverse effects," said Dr. Nikolaus Marx, professor and director of medicine at Aachen (Germany) University Hospital.
Other groups came first
As Dr. Smith noted, the ESC is not the first medical group to scale back aggressive blood pressure targets for patients with diabetes or chronic kidney disease, but it may be the first major cardiology society to do so. Last year, the Kidney Disease Improving Global Outcomes foundation issued guidelines for hypertension management in patients with chronic kidney disease (Kidney International Supplement 2012;2:340-414). The expert panel recommended a target pressure of 140/90 mm Hg or below for patients with chronic kidney disease with or without diabetes as long as their daily urine albumin remained below 30 mg. For patients with more severe albuminuria, the panel recommended a target of 130/80 mm Hg or less for all chronic kidney disease patients regardless of their diabetes status.
Earlier this year, the American Diabetes Association published its Standards of Medical Care in Diabetes–2013, which set a target blood pressure for patients with diabetes at less than 140/80 mm Hg (the ESC set a diastolic pressure target of less than 85 mm Hg) (Diabetes Care 2013;36:S11-S66).
Other changes in the ESC guidelines
The ESC guidelines include some other notable changes (Euro. Heart J. 2013;34:2159-219):
• The basic systolic blood pressure goal for elderly patients, defined as 65 years or older, was set as less than 150 mm Hg. The goal can lower to less than 140 mm Hg for "fit elderly patients" younger than 80 years old if treatment is well tolerated.
• The guidelines place new emphasis on using some method for out-of-office blood pressure measurement – either ambulatory or home-based blood pressure measurement – for patients suspected of having either false-positive office-based blood pressure measurements (white coat hypertension) or false-negative office blood pressure levels (masked hypertension).
• The universe of first-line antihypertensive medications was whittled down to four: thiazide diuretics, calcium channel blockers, ACE inhibitors, and angiotensin-receptor blockers. Although the new guidelines call beta-blockers a "cornerstone" of treatment for patients with coronary heart disease and tachyarrhythmias, including atrial fibrillation, they are no longer seen as first-line agents for patients without these coexisting cardiac diseases or for young patients.
• A section on treating hypertension in young adults encourages applying the below 140/90 mm Hg target to these patients as well after a reasonable attempt at lifestyle intervention only.
• An updated approach to managing gestational hypertension and preventing preeclampsia includes use of prophylactic aspirin by women at moderate or high risk of preeclampsia, and treating pregnant women to a blood pressure of less than 150/95 mm Hg if pressure this high is persistent, or to a target of less than 140/90 mm Hg in women with gestational hypertension, symptoms, or subclinical organ damage.
Dr. Smith and Dr. Williams said that they had no relevant disclosures. Dr. Mancia said that he has been a consultant to 14 drug and device companies. Dr. Renata Cífková said that she had been a consultant to Daiichi Sankyo, Teva, Zentiva, Merck Sharpe and Dohme, Actavis, Berlin Chemie, Boehringer Ingelheim, and Bayer. Dr. Marx said that he has been a consultant to 13 drug and device companies. Dr. Williams said that he has been a consultant to Pfizer, Merck, Sanofi-BMS, and Novartis.
On Twitter @mitchelzoler
AMSTERDAM – When the European Society of Cardiology in June reset its target systolic blood pressure for patients with diabetes, chronic kidney disease, or a history of cardiovascular disease to less than 140 mm Hg, it joined a small but growing cadre of medical societies that have looked at recent evidence and concluded that nothing currently justifies treating to a target systolic blood pressure below 130 mm Hg or to a diastolic pressure below 80 mm Hg.
The European Society of Cardiology’s new edition of hypertension management guidelines, produced in collaboration with the European Society of Hypertension, contrasts with the conspicuous void in U.S. practice that’s been widely acknowledged for a few years now: the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the prevailing version of U.S. hypertension-management guidelines, is a decade old and outdated.
The delay-plagued process to come out with the eighth JNC edition (JNC 8) took an unexpected turn last June, when the National Heart, Lung, and Blood Institute, the agency that shepherded the first seven editions of U.S. hypertension guidelines going back to 1976, announced that it was immediately turning responsibility for getting JNC 8 finalized and out to the public over to "partner organizations" such as the American College of Cardiology and American Heart Association.
With this new wrinkle, even with the ACC and AHA scrambling to deal with their new responsibility, it seems like JNC 8 – or whatever name it will have when it finally emerges – will not come out until 2014 at the soonest, making the ESC guidelines the only up-to-date hypertension recommendations from a cardiology-oriented medical group for at least several more months.
A U.S. view of the Euro guidelines
"U.S. physicians need to be aware of the evidence as it evolves," said Dr. Sidney C. Smith Jr., professor of medicine at the University of North Carolina in Chapel Hill, and a member of the panel that’s been writing JNC 8.
"The American Diabetes Association came out with a similar recommendation" on the systolic blood pressure target for patients with diabetes. U.S. physicians should "see what the ADA says, see what the ESC says, and then decide what they should do. They need to read the recommendations and supporting evidence and see if it applies to their patients," Dr. Smith advised in an interview. "I think that patients and physicians will look at the current evidence and respond. You’ve got to go with what the evidence says and what seems best for the patient. No law says that you shall only do what is in the" JNC 7 guidelines.
A trickier situation may be settings in which physicians are assessed based on how many of their patients with diabetes reach a blood pressure target of less than 130/80, he said. "How do health care systems respond to evidence as it evolves? At what point should performance measures get changed?" Dr. Smith asked.
But because of its orientation to European populations, the new ESC hypertension guidelines can’t completely fill the U.S. vacuum.
"I’m sure JNC 8 will be nuanced differently than the European guidelines because we have a different population in the U.S., particularly African Americans and more patients with renal failure," said Dr. Kim Allan Williams Sr. of Wayne State University, Detroit. Dr. Williams will take the position of professor of medicine and chief of cardiovascular services at Rush University Medical Center in Chicago on Nov. 1. "As a practitioner, I would worry about using 140/90 mm Hg as the only target for the African American population that I deal with all the time. The stroke and renal failure rates are much higher in these patients" than in other patients with hypertension, he said in an interview. "The new European guidelines don’t deal with patients with African ancestry. JNC 7 had a section on blood pressure management in minority groups, which was very helpful."
Resetting the target for diabetics
The dialing up of the target systolic blood pressure for patients with diabetes or other high-risk factors, and the resulting damping down of antihypertensive treatment intensity, is the biggest change in the 2013 ESC hypertension recommendations, said Dr. Giuseppe Mancia, who chaired the task force that wrote the recommendations.
"We need to base the recommendations on the evidence. It’s been a consistent finding, in ONTARGET, ACCORD, and in other studies, that pushing the blood pressure of patients with diabetes below 130 mm Hg provided no additional benefit but was linked with more adverse events. If you set a lower target you need to be absolutely sure there is no harm associated with it, and at the moment we cannot say that.
"Adverse events [leads to] more discontinuation of treatment, and there is now evidence that discontinuation is closely related to an increase in events," said Dr. Mancia, professor of medicine at the University of Milan and cochair of the ESC hypertension task force. "There is a remarkable relationship between longer time taking antihypertensive drugs and cardiovascular protection."
"We were probably too radical in the previous guidelines" in setting a target systolic pressure at less than 130 mm Hg, said Dr. Renata Cífková, professor and head of preventive cardiology at Thomayer Teaching Hospital in Prague and a member of the ESC hypertension panel. "We saw that this was not evidence based. When we reviewed the same studies and also included the newer studies, like ACCORD, it basically confirmed our new blood pressure targets." Another advantage is that patients and physicians "will feel more comfortable with these goals," both in their achievability and by producing fewer adverse events," she said in an interview.
"This is the first major change in the hypertension guidelines for a number of years," the first full update since 2007, said Dr. Bryan Williams, professor and chairman of medicine at University College, London. "The data presented showed that, while there is indisputable evidence to lower pressures below 150/90 mm Hg, and strong evidence to lower below 140/90 mm Hg, there is limited or no evidence to recommend lowering pressures to below 130/80 mm Hg, and in some situations there is evidence for a signal of harm," said Dr. Williams. "The new guidelines simplify the target, a blood pressure of less than 140 mm Hg for everyone, regardless of their level of risk."
"The change in target means that ‘the lower the better’ is no longer true. This will reduce the number of drugs that patients receive and will avoid some adverse effects," said Dr. Nikolaus Marx, professor and director of medicine at Aachen (Germany) University Hospital.
Other groups came first
As Dr. Smith noted, the ESC is not the first medical group to scale back aggressive blood pressure targets for patients with diabetes or chronic kidney disease, but it may be the first major cardiology society to do so. Last year, the Kidney Disease Improving Global Outcomes foundation issued guidelines for hypertension management in patients with chronic kidney disease (Kidney International Supplement 2012;2:340-414). The expert panel recommended a target pressure of 140/90 mm Hg or below for patients with chronic kidney disease with or without diabetes as long as their daily urine albumin remained below 30 mg. For patients with more severe albuminuria, the panel recommended a target of 130/80 mm Hg or less for all chronic kidney disease patients regardless of their diabetes status.
Earlier this year, the American Diabetes Association published its Standards of Medical Care in Diabetes–2013, which set a target blood pressure for patients with diabetes at less than 140/80 mm Hg (the ESC set a diastolic pressure target of less than 85 mm Hg) (Diabetes Care 2013;36:S11-S66).
Other changes in the ESC guidelines
The ESC guidelines include some other notable changes (Euro. Heart J. 2013;34:2159-219):
• The basic systolic blood pressure goal for elderly patients, defined as 65 years or older, was set as less than 150 mm Hg. The goal can lower to less than 140 mm Hg for "fit elderly patients" younger than 80 years old if treatment is well tolerated.
• The guidelines place new emphasis on using some method for out-of-office blood pressure measurement – either ambulatory or home-based blood pressure measurement – for patients suspected of having either false-positive office-based blood pressure measurements (white coat hypertension) or false-negative office blood pressure levels (masked hypertension).
• The universe of first-line antihypertensive medications was whittled down to four: thiazide diuretics, calcium channel blockers, ACE inhibitors, and angiotensin-receptor blockers. Although the new guidelines call beta-blockers a "cornerstone" of treatment for patients with coronary heart disease and tachyarrhythmias, including atrial fibrillation, they are no longer seen as first-line agents for patients without these coexisting cardiac diseases or for young patients.
• A section on treating hypertension in young adults encourages applying the below 140/90 mm Hg target to these patients as well after a reasonable attempt at lifestyle intervention only.
• An updated approach to managing gestational hypertension and preventing preeclampsia includes use of prophylactic aspirin by women at moderate or high risk of preeclampsia, and treating pregnant women to a blood pressure of less than 150/95 mm Hg if pressure this high is persistent, or to a target of less than 140/90 mm Hg in women with gestational hypertension, symptoms, or subclinical organ damage.
Dr. Smith and Dr. Williams said that they had no relevant disclosures. Dr. Mancia said that he has been a consultant to 14 drug and device companies. Dr. Renata Cífková said that she had been a consultant to Daiichi Sankyo, Teva, Zentiva, Merck Sharpe and Dohme, Actavis, Berlin Chemie, Boehringer Ingelheim, and Bayer. Dr. Marx said that he has been a consultant to 13 drug and device companies. Dr. Williams said that he has been a consultant to Pfizer, Merck, Sanofi-BMS, and Novartis.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE ESC CONGRESS 2013
