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ESC Guidelines 2014 Overview

ESC Congress Report

  • Close monitoring and possible thrombolysis in patients with intermediate-high risk pulmonary embolism
  • Myocardial Revascularization: Choice of PCI vs CABG depends heavily on Syntax score
  • Aortic disease: Screening for abdominal aortic aneurysm recommended in female smokers and all men  aged 65 or more
  • HCM: Comprehensive evaluation required
  • Peri-operative care in non-cardiac surgery: ischemia testing in patients with limited exercise capability and high risk surgery

The new Guidelines on Pulmonary Embolism, presented by Stavros  Konstantinides,  emphasize the initial assessment of hemodynamically unstable patients versus stable patiens. Unstable patients are those with shock or hypotension, they are high-risk and candidates for thrombolysis. Using clinical scores and the D Dimer test, stable patients should be classified as low risk, with no further treatment, or intermediate risk. In intermediate risk patients, biomarkers and imaging of right ventricular dysfunction (CT or echocardiography) are used to identify an intermediate-high risk subgroup which should be closely monitored for signs of hemodynamic compromise and, if such signs develop, thrombolysis should be considered (Class IIa recommendation). For anticoagulation in the acute phase, NOACS now carry the same class of recommendation as vitamin K antagonists (with the important exception of patients in renal failure).

Stephan Windecker, Bern, and Philippe Kolh, Liege, reported on the Guidelines for Myocardial Revascularization, which in a comprehensive way cover the selection of patients for revascularization, the revascularization method and procedure itself, as well as adjunct pharmacotherapy. Importantly, revascularization of patients with stable CAD improves prognosis if carried out by bypass surgery or with the use of new-generation DES. The choice of PCI versus CABG has been influenced by the long term results of the SYNTAX studies, so that PCI is now considered equal to CABG in single and two-vessel vessel disease with and without proximal LAD involvement, in patients with left main or three-vessel disease disease up to a SYNTAX score of 22. The guidelines contain detailed information on antiplatelet treatment. Dual antiplatelet treatment is now recommended for 6 months after DES implantation and a shorter duration may be considered in patients at high bleeding risk.

When Perry Elliott presented the new guidelines on Hypertrophic Cardiomyopathy (HCM), he stressed the fact that a very comprehensive, detailed and individual assessment of each patient must be undertaken, including history taking (with family history a major component), clinical assessment and imaging. While HCM is defined as LV thickening of  15 mm or more in any LV segment and by any imaging modality, and echocardiography carries a clear Class I recommendation to be performed in all individuals, cardiac magnetic resonance with late enhancement should be performed with a Class I indication whenever possible. For risk assessment, however, the presence of late enhancement in MRI is not yet considered. Dr. Elliott pointed out that genetic testing always needs to be accompanied by genetic counseling. Therapy relies on non-vasodilating beta blockers, or, if beta blockers are contraindicated, verapamil.  Septal reduction therapy is limited to symptomatic patients  with a resting or maximum LVOT gradient of at least 50 mmHg despite medical therapy.

The Guidelines on Aortic Diseases were presented by Raimund Erbel and Victor Aboyans. They cover both acute aortic syndromes and chronic diseases. They emphasize that the entire aorta should be evaluated in all patients. This included assessment of the abdominal aorta in patients with thoracic aortic aneurysm or dissection and vice versa. In acute aortic syndromes, intramural hematoma carries the same prognostic relevance as aortic dissection and needs to undergo urgent surgery of the ascending aorta is affected.  In chronic ascending thoracic aortic aneurysms, the threshold for elective surgery depends on the aortic root diameter (usually 55 mm), but also on accompanying conditions – such a a bicuspid aortic valve (50 mm) or Marfan´s Syndrome (45 mm). Improtantly, the guideline now recommends screening for abdominal aortoc aneurysms in males above 65 years and female smokers above 65 years. In fact, it is recommended that during routine echocardiography, a quick assessment and measurement of the abdominal aorta is included in these patients.

Finally, Drs. Juhani Knuuti and Steen Dalby Kristensen presented the updated guidelines on Cardiovascular Assessment and Management in Non-Cardiac Surgery, jointly created by the ESC and European Society of Anesthesiology. In patients with unstable cardiac conditions, surgery should be postponed whenever possible. Elective surgery should  be classified as low, intermediate or high risk and low risk surgery such as eye surgery or minor orthopedic surgery requires no workup. High risk procedures include aortic and vascular surgery,limb amputation,  pneumectomy, and large abdominal surgery. Only in patients with high risk surgery and limited exercise capacity, stress testing is recommended and revascularization should be considered accordingly. The choice of revascularization has an influence on how rapidly surgery can be performed (POBA: 2 weeks, PCI with BMS 4 weeks, with DES 6-12 months, CABG immediately). Peri-operative continuation of beta blockers has a class I recommendation on patients with previous beta blocker therapy. In patients with high risk surgery and at least 2 cardiovascular risk factors or ischemic heart disease the initiation of a new beta blocker may be considered (Class IIb), but high-dose therapy without titration is not recommended (Class III). Statin therapy should be maintained (Class I) or, if not presently administered, initiation should be considered in patients scheduled for vascular surgery.

In summary, the presented guidelines represent the comprehensive, careful and practical character of all ESC guidelines and, with the depth of information and advice they contain, will be a tremendously useful resource for the everyday management of routine and challenging patients in clinical practice.


ESC Guidelines 2014 Overview

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.