Reference: March 2024 | Issue 3 | Vol 10 | Page 10
A round-up of three new European Society of Cardiology (ESC) guidelines, which were presented at the ESC Congress in Amsterdam, 26-28 August 2023
New ESC updated guidelines on diagnosis and treatment of acute and chronic heart failure
A focused update of the 2021 European Society of Cardiology (ESC) guidelines for heart failure (HF) was presented at the 2023 ESC Congress in Amsterdam by Prof Marco Metra, University of Brescia, Brescia, Italy; and Prof Theresa McDonagh, King’s College Hospital, London, UK; Chairs of the original guidelines taskforce.
“Since the 2021 ESC guidelines for HF, more than 10 randomised controlled trials have been published that should change patient management ahead of the next scheduled full guideline. Based on this recent evidence, new recommendations are provided in three areas: Chronic HF, acute HF, and comorbidities,” Prof Metra said, explaining the need for the update.
Regarding chronic HF, there were no recommendations in the 2021 guidelines on the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors in patients with HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF) as there was a lack of evidence. Since then, the EMPEROR-Preserved and DELIVER trials have been published and the focused update now recommends dapagliflozin or empagliflozin in patients with HFmrEF and HFpEF to reduce the risk of HF hospitalisation or cardiovascular (CV) death.
“The taskforce also discussed changing the description of HFpEF to ‘HF with normal ejection fraction (HFnEF)’ and altering the left ventricular ejection fraction threshold for HFnEF,” noted Prof McDonagh. “However, we ultimately decided to keep the term ‘HFpEF’ and we left any further changes in terminology to be considered by the next ESC HF guidelines taskforce.”
For acute HF management after hospital admission, the STRONG-HF trial recently showed the safety and efficacy of an approach based on starting and titrating oral HF therapies within two days before anticipated hospital discharge and in follow-up visits occurring early after discharge.
These findings led to a new recommendation of high-intensity care for initiation and rapid up-titration of oral HF therapies with close follow-up in the first six weeks after discharge to reduce HF readmission or all-cause death. The focused update stresses that particular attention should be paid to symptoms and signs of congestion, blood pressure, heart rate, NT-proBNP values, potassium concentrations, and estimated glomerular filtration rate (eGFR) during follow-up appointments.
Turning to comorbidities, the focused update provides a new recommendation for the prevention of HF in patients with chronic kidney disease (CKD) and type 2 diabetes (T2DM) based on the results of the DAPA-CKD and EMPA-KIDNEY SGLT2 inhibitor trials and a meta-analysis of four trials.
Dapagliflozin or empagliflozin are now recommended for patients with CKD and T2DM to reduce the risk of HF hospitalisation or CV death. A second recommendation follows the FIDELIO-DKD and FIGARO-DKD trials, and advocates the use of the mineralocorticoid receptor antagonist, finerenone, in patients with CKD and T2DM to reduce the risk of HF hospitalisation.
Reference
McDonagh TA, et al; SC Scientific Document Group. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023; ehad195.
2023 ESC clinical practice guidelines for the management of cardiovascular disease in patients with diabetes
Newly-updated European Society of Cardiology (ESC) guidelines for the management of cardiovascular disease (CVD) in patients with diabetes were launched by Prof Nikolaus Marx, RWTH Aachen University, Aachen, Germany; and Prof Massimo Federici, University of Rome Tor Vergata, Rome, Italy; Chairs of the guidelines taskforce, during the 2023 ESC Congress.
A key change from the previous 2019 edition is that the 2023 guidelines only focus on CVD and diabetes, and do not consider pre-diabetes due to the lack of clear evidence.
Another important concept modification is the way that cardiovascular (CV) risk should be assessed in patients with diabetes. All patients with diabetes should be evaluated for the presence of CVD and severe target-organ damage, which is defined based on estimated glomerular filtration rate (eGFR), urinary albumin-to-creatinine ratio (UACR), or the presence of microvascular disease in at least three different sites (eg, microalbuminuria plus retinopathy plus neuropathy).
For patients with type 2 diabetes (T2DM), but without atherosclerotic CVD or severe target-organ damage, the new guidelines introduce a novel, dedicated T2DM-specific 10-year CVD risk score – the SCORE2-Diabetes algorithm. SCORE2-Diabetes integrates information on conventional CVD risk factors (ie, age, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol) with diabetes-specific information (ie, age at diabetes diagnosis, HbA1c, and eGFR) to classify patients as low, moderate, high, or very high CV risk.
Given the high prevalence of undetected diabetes in patients with CVD, as well as the elevated risk and therapeutic consequences if both comorbidities co-exist, the new guidelines also recommend systematic screening for diabetes in all patients with CVD.
Over the last decade, various large CV outcome trials in patients with diabetes at high CV risk have studied sodium–glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and a non-steroidal mineralocorticoid receptor antagonist, substantially expanding available therapeutic options.
Based on this evidence, the current guidelines provide clear recommendations on how to treat patients with diabetes and clinical manifestations of cardiovascular-renal disease. As such, in patients with diabetes and atherosclerotic CVD, treatment with GLP-1 RAs and/or SGLT2 inhibitors is recommended to reduce CV risk, independent of glucose control and in addition to standard of care, eg, anti-platelet, anti-hypertensive, and lipid-lowering therapy.
“Just as the presence of T2DM informs the prescription of other cardioprotective therapies such as statins regardless of glycaemic considerations, the same should now apply to prescribing SGLT2 inhibitors and/or GLP-1 RAs,” said Prof Federici.
A special focus of the new guidelines is on managing heart failure in diabetes, a field that has been underestimated for years.
A systematic survey for heart failure signs and symptoms is recommended at each clinical encounter in all patients with diabetes. Based on data from large trials, it is recommended that patients with diabetes and chronic heart failure (HF), regardless of left ventricular ejection fraction, are treated with an SGLT2 inhibitor to reduce HF hospitalisation or CV death.
Opportunistic screening for atrial fibrillation (AF) by pulse taking or ECG now has a Class I recommendation in patients with diabetes aged ≥65 years. Given that patients with diabetes exhibit a higher AF frequency at a younger age, the concept of opportunistic screening for AF by pulse-taking or ECG in patients with diabetes <65 years of age – particularly when other risk factors are associated – is also introduced.
A dedicated section has been included on managing CV risk in patients with chronic kidney diesase (CKD) and diabetes, covering aspects of screening (including regular screening with eGFR and UACR) and treatment. All patients with diabetes should be evaluated for risk and presence of CKD, and where detected, it is recommended to treat with an SGLT2 inhibitor and/or finerenone to reduce CV events and kidney failure risk.
Overall, identifying and treating risk factors and comorbidities early is recommended.
Reference
Marx N, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023;ehad192.
2023 ESC clinical practice guidelines for the management of acute coronary syndromes
New European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes (ACS) were presented at the ESC Congress by Prof Robert A Byrne, Mater Private Network and RCSI, Dublin; and Prof Borja Ibanez, Spanish National Centre for Cardiovascular Research (CNIC) and Fundación Jiménez Díaz University Hospital-CIBERCV, Madrid, Spain; Chairs of the guidelines taskforce.
“Previous ESC guidelines dealt with ST-elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS) separately, but these have been brought together in the 2023 guidelines to highlight that ACS should be considered as a spectrum that encompasses both,” said Prof Byrne.
Diagnostic tests, invasive procedures, and pharmacological treatments are pretty much the same across the spectrum, and differences in the management between the different forms of presentation of ACS relate to the time of invasive coronary angiography. This should be immediately for STEMI and very high-risk NSTE-ACS, with a less emergent nature for NSTE-ACS. For the latter, it is recommended that invasive strategy is performed during hospitalisation (inpatient), and in some cases (ie, patients with high-risk characteristics), it should be considered to do so within 24 hours of admission (early invasive strategy).
After the acute management and stabilisation phase, most aspects of the subsequent management strategy are common to all patients with ACS and can therefore be considered under a similar pathway. Accordingly, “it makes a lot of sense to combine the former two guidelines into a single document, which we hope will be very useful for healthcare providers attending ACS patients,” said Prof Ibanez.
There are 37 new recommendations on topics including the use of antiplatelet and anticoagulation therapy, treating multivessel disease, managing ACS complications, and intensification of lipid-lowering therapy. In addition, new recommendations are given on comorbid conditions, including six that are relevant to ACS patients with cancer.
Prof Ibanez explained: “Cancer patients with ACS have been reported to undergo invasive management less frequently; however, invasive management is recommended in cancer patients presenting with high-risk ACS with expected survival of six months or more. A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis, (ie, with expected survival <six months) and/or very high bleeding risk.” Temporary interruption of cancer therapy is recommended when it is suspected to be a contributing cause of ACS.
Also new is a section on patient perspectives. Prof Byrne drew attention to the opinion of the ESC taskforce that management should not only consider the best available evidence with regard to clinical treatment strategies, but should also be respectful of and responsive to individual patient preferences, needs, and values, ensuring that these values are used to inform all clinical decisions. It is recommended to include patients in decision-making where possible and to inform them about the risk of adverse events, radiation exposure, and alternative options.
The new guidelines also advocate preparing for discharge on admission and integrating educationally-appropriate material in both written and verbal formats. The ‘teach back’ technique and/or motivational interviewing, giving information in chunks and checking for understanding, should be considered. Regarding long-term management, it is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, multidisciplinary exercise-based cardiac rehabilitation and prevention programme, and adopt a healthy lifestyle.
Reference
Byrne RA, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;ehad191.
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