The European Society of Cardiology (ESC) has published two new guidelines – ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012, and European Guidelines on cardiovascular disease prevention in clinical practice (version 2012).
Heart failure
The recommendations on devices, drugs and diagnosis in heart failure were developed by the ESC in collaboration with a heart failure association of the ESC.
There have been several major updates since the previous guidance published in 2008. The new updates include:
In devices, left ventricular assist devices (LVADs) have been hailed as a step change in the management of heart failure. LVADs are more reliable and lead to fewer complications than in 2008. Until now, LVADs have been used as a temporary measure in patients awaiting a heart transplant. Professor John McMurray (Glasgow, UK), chairperson of the ESC Clinical Practice Guidelines Task Force, says: “LVADs will increasingly be used as a treatment in their own right, not just as a temporary support while awaiting transplantation”. Also in the device arena, new transcatheter valve interventions are discussed. “These interventions offer the possibility of treating aortic stenosis in patients who are unsuitable for surgery,” says Professor McMurray.
A new indication for cardiac resynchronisation therapy (CRT) in patients with mild symptoms. More evidence from new trials and further analysis of existing trials enabled the task force to provide more clarity about the effects of CRT. Patients with left bundle branch block QRS morphology and those who are in sinus rhythm have the greatest benefit from CRT. Conversely, those who have a non-left bundle branch block QRS morphology and patients in atrial fibrillation have less certain benefit.
In pharmacological treatments, two new indications are highlighted. The guidelines stress that when attempting to reduce heart rate, the dose of beta blocker should be maximised before giving additional medications to reduce heart rate. New evidence has extended the indication for mineralocorticoid receptor antagonists. This means that for many patients, standard therapy should include three neurohumoral antagonists – an angiotensin converting enzyme inhibitor (or angiotensin receptor blocker), a beta blocker and, if symptoms persist, now a mineralocorticoid receptor antagonist as well.
In the area of diagnostics, a new biomarker called mid-regional pro-A-type natriuretic peptide is mentioned for the first time.
The full guidance is available at http://eurheartj.oxfordjournals.org/content/33/14/1787 (Eur Heart J 2012;33:1787–847).
CVD prevention
The cardiovascular disease (CVD) prevention guidelines have been developed by the Fifth Joint Task Force of societies of Cardiovascular Disease Prevention in Clinical Practice, which includes the European Society of Cardiology (ESC) and seven other societies.
Around one third shorter than the 2007 fourth edition, the guidelines have been overhauled to produce a user friendly document with concise messages that awards greater weight than ever before to evidence from clinical trials and observational population studies.
“We’ve designed the Guidelines in a new format that makes them much more accessible,” explained Professor Joep Perk, the chairperson of the Guidelines Task Force. “The change is to help disseminate the information from the Guidelines out to where it’s needed”.
The Guidelines stress that CVD prevention should be a “lifelong effort”. Greater emphasis has been placed on the behavioural aspects of prevention, with discussion of ways to make it easier for patients to change their lifestyles.
The guidelines highlight the following:
The urgent need to improve CVD prevention. CVD is still the leading cause of premature death world-wide, the vast majority of which might be prevented through the widespread adoption of simple interventions such as smoking cessation, improved diets and increased exercise.
Greater emphasis on population studies. For the first time the Grading of Recommendations Assessment Development and Evaluation (GRADE) system has been used to assess medical evidence that gives increased weight to population studies. This is in addition to the traditional assessment, applied by the ESC in all its Guidelines.
Comprehensive and wide ranging to cover all areas of prevention, including total cardiovascular risk estimation, diseases with increased risk for CVD, methods of CVD prevention, smoking cessation interventions, dietary habits, physical activity, psychosocial factors, body weight, blood pressure, type 2 diabetes, lipids, and antithrombotic therapies.
The full guidance is available at http://eurheartj.oxfordjournals.org/content/33/13/1635 (Eur Heart J 2012:33;1635–701).
