Prof. Stephan Achenbach,
The guidelines pertaining to cardiovascular medicine issued by the European Society of Cardiology are a tremendously important resource, both for cardiologists and also for other physicians. Accordingly, the large Central arena was crowded on Sunday morning at 8:30 when the Task Force chairpersons presented four new guidelines that are being released in the context of the ESC 2013 Udo Sechtem and Gilles Montalescot presented the new guidelines on stable coronary artery disease. Major changes as compared to the 2006 version of these guidelines include a clear three-step approach to diagnostic assessment: A clinical estimate of disease likelihood is the first step, and no further steps are taken if that likelihood is less than 15%. In patients with a likelihood between 15 and 85%, non invasive diagnostic testing is recommended to establish the diagnosis. Stress ECG has lost importance, and is no longer recommended in individuals with a likelihood > 65% or impaired LV function. It should be replaced by imaging-based stress testing where possible. Coronary CT angiography should be considered in suitable patients with a pre-test likelihood up to 50%. Invasive coronary angiography is limited to patients with severe angina, ongoing angina despite treatment, and high-risk features on non-invasive testing. If no ischemia test is available, fractional flow reserve (FFR) assessment is strongly recommended. Michele Brignole presented the new guidelines on pacing and resynchronization. Importantly, he introduced a new classification of syncope, no longer depending on the pathophysiology or underlying disease, but rather on the ECG documentation. Pacing, referred to by him as "the best weapon against bradycardia", is clearly indicated when there is ECG documentation of bradycardia. Further testing is mandatory when there is no ECG documentation of bradycardia, with carotid massage, potentially electrophysiological study and implantation of a loop recorder. The indication for resynchronization therapy in patients with ejection fraction < 35% depends on bundle branch block / wide QRS and not on the documentation of dyssynchrony. The possibility to perform magnetic resonance imaging in patients with devices is relatively liberal, but close surveillance and device reprogramming is required. Lars Ryden and Peter Grant presented the guidelines on diabetes, pre-diabetes and cardiovascular disease. For diagnosis, HbA1c levels are of importance. In low risk individuals, a HbA1c level <7% is sufficient to rule out the diagnosis, while in patients with coronary disease, this is not sufficient and an oral glucose tolerance test should be performed. Target levels for treatment are, in general, a HbA1c level <7.0%, but can be between 6.0% and 6.5% in younger individuals with a long life expectancy, and less stringent (up to 8.0%) in elderly patients. Aspirin is not recommended in diabetic patients without cardiovascular disease. It is no longer recommended to stop metformin before invasive coronary angiography or percutaneous coronary intervention, but renal function should be closely monitored and medication withheld for 48 hours or until improvement of renal function. Robert Fagard and Giuseppe Mancia presented the hypertension guidelines. The diagnosis of hypertension remains based on a threshold of 140/90mmHg, but treatment goals have become somewhat more conservative, and even in high risk patients, it is no longer considered necessary to lower the systolic blood pressure to below 130 mmHg. 140/90 mmHg is the treatment goal for all, except the elderly, where higher systolic levels are acceptable and treatment intensity depends also on medication tolerance and side effects. All classes of hypertensive agents are considered useful for monotherapy, including beta blockers, around which there has been some discussion in the past years. In general, combination therapy of two drug classes is favoured over changing the drug or increasing the dose if monotherapy fails to be sufficiently effective. However, the combination of ACE inhibitors and ARB is not recommended.
ESC Guidelines 2013 overview
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