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The “Ten Commandments” of ESC Guidelines 2014
The new ESC journal EHJs
Tour de Coeur - Tour Diary

THE "TEN COMMANDMENTS" OF THE ESC GUIDELINES 2014

Guidelines on Non-Cardiac Surgery: Cardiovascular Assessment & Management; by Steen D Kristensen MD and Juhani Knuuti MD

SK and JK
Steen D Kristensen and Juhani Knuuti
Photo: Roni Lehti
1. A multidisciplinary expert team should be consulted for preoperative evaluation of patients with known or high risk of cardiac disease undergoing high-risk non-cardiac surgery.

2. The surgical risk assessment - which depends on the planned procedure - has been completely updated. Further, when alternative methods to the classical open surgery are considered - either through endovascular or less invasive endoscopic procedures - the potential trade-offs between early benefits due to reduced morbidity and mid-long term efficacy must be considered. Accordingly, the GL recommends that patients should undergo preoperative risk assessment independently of an open or laparoscopic surgical approach.

3. The patient risk assessment now includes not only the Lee score but also other validated risk scores such as NSQIP. The new version also has recommendations about the role of biomarkers (BNP and Troponins) for risk assessment.

4. The risk reduction section has also been completely updated. The key change is that preoperative initiation of beta-blockers is not recommended in all patients but may be considered in patients scheduled for high-risk surgery and who have clinical risk factors, or who have known ischaemic heart disease or myocardial ischaemia. When initiated, the dose should be titrated. If the patient has already had beta-blocker therapy before surgery, continuation is recommended.

5. The recommendation of the use of aspirin and P2Y12 inhibitors for patients undergoing non-cardiac surgery has been updated. New oral anticoagulants are now available and recommendations on how to manage patients treated with these drugs undergoing non-cardiac surgery is described in a new section.

6. The recommendations for the timing of non-cardiac surgery in cardiac-stable/asymptomatic patients with previous revascularization has also been updated by considering new information on safety margins after various revascularization procedures. As in previous GL, routine prophylactic myocardial revascularization before low- and intermediate-risk surgery in patients with proven IHD is not recommended but may be considered before high-risk surgery, depending on the extent of a stress-induced ischaemia.

7. The entire section on specific diseases has been completely updated and several new sections have been added. The section now covers numerous conditions that will influence preoperative evaluation, i.e. chronic heart failure, arterial hypertension, valvular heart disease, arrhythmias, renal disease, carotid disease, peripheral artery disease, pulmonary artery hypertension and pulmonary disease as well as congenital heart disease.

8. The perioperative monitoring section has also been updated and expanded by the anaesthesia experts from European Society of Anaesthesiology. This section now includes parts on intra-operative anaesthetic management, neuraxial techniques, peri-operative goal-directed therapy, risk stratification after surgery, early diagnosis of post-operative complications and postoperative pain management, as well as specific recommendations about the anaesthesia.

9. Naturally, these numerous changes also led to major revisions of the summary table and step-by-step guidance sections at the end of the document. However, this section was considered very useful for users and these revisions were successfully managed. The recommendations for the step-by-step approach as well as one comprehensive table summarizing most of the recommendations are included in the guideline document as well is in the pocket guideline.

10. Randomized clinical trials on the perioperative use of beta-blockers and other drugs are highly needed.

Guidelines on Diagnosis & Management of Hypertrophic Cardiomyopathy; by Perry Elliott MD

PE
Perry Elliott
1. Clinicians should consider referral of patients to multidisciplinary teams with expertise in the diagnosis, genetics, risk stratification and management of heart muscle disease.

2. A clinically focused approach to the diagnosis of genetic and acquired causes of HCM based on careful history including analysis of family pedigrees and a cardiomyopathy-centred interpretation of commonly used diagnostic tools such as electrocardiography and cardiac imaging should be adopted.

3. Genetic counselling is recommended in all patients with unequivocal HCM when it cannot be explained solely by a non-genetic cause

4. When a definite causative genetic mutation is identified in a patient, his or her first degree relatives should first be genetically tested, and then clinically evaluated if they are found to carry the same mutation.

5. Exercise stress echocardiography is recommended in symptomatic patients with LVOT gradient <50 mmHg at rest.

6. When a gradient is detected in the left ventricle cavity, obstruction caused by sub-aortic membranes, structural mitral valve leaflet abnormalities and mid-cavity obstruction should be systematically excluded.

7. Use of a new risk calculator (HCMRisk-SCD) is recommended to guide the use of implantable cardioverter defibrillators (ICD).

8. Patients with HCM and paroxysmal, persistent or permanent atrial fibrillation should receive treatment with vitamin K antagonists and lifelong therapy with oral anticoagulants is recommended, even when sinus rhythm is restored.

9. Patients in sinus rhythm with left atrium diameter ≥45 mm should undergo 6–12 monthly 48-hour ambulatory ECG monitoring to detect AF.

10. Most women with HCM tolerate pregnancy well but require expert advice before conception and throughout pregnancy.

Guidelines on Myocardial Revascularization; by Pieter Kappetein MD

PE
Pieter Kappetein
1. Revascularization through CABG or PCI is recommended for patients with angina symptoms despite optimal medical therapy, patients who prefer PCI to medical therapy and for those with lesions with a proven survival benefit.

2. CABG is recommended in patient with a primary indication of aortic or mitral valve surgery and coronary artery diameter stenosis of more than 70%.

3. Risk stratification and scores: STS score, Euroscore II and Syntax II factor into assessing patients undergoing revascularization. But clinical judgment and a heart team decision in complex cases is mandatory. Patients should be adequately informed of short-term risk and long-term benefits of revascularization procedures.

4. FFR during diagnostic angiography often changes management decision; nearly 50% of coronary artery stenoses in the intermediate range are functionally misclassified.

5. Due to long-term survival benefit CABG is preferred in cases of complex CAD.

6. Patients with proximal LAD disease in whom revascularization is recommended can be revascularized with PCI. The CABG option should be offered and the exchange of higher early morbidity vs a lower rate of repeat revascularization should be discussed.

7. Multiple arterial grafts are recommended for younger patients undergoing revascularization with CABG.

8. Optimal medical treatment should accompany revascularization with focus on risk factor reduction

9. Graft flow measurement may be useful in patients with hemodynamic instability or inability to wean from extracorporeal circulation.

10. Off pump surgery does not seem to improve short or long-term outcome for most patients and is associated with inferior early and late graft patency rates.

Guidelines on Aortic Diseases; by Raimund Erbel MD

PE
Raimund Erbel
1. First guideline on diseases of the thoracic and abdominal aorta as one organ including not only acute aortic syndromes, but also aortic aneurysms, genetic and congenital diseases, aortic inflammation and aortic tumours.

2. Modern imaging of the aorta permits visualization of the total aorta requiring standardized reports and measurements at given landmarks.

3. A two-minute added scan of the abdominal aorta, should be used in all elderly patients undergoing transthoracic echocardiography to effectively screen for abdominal aortic aneurysms (AAA).

4. A comprehensive list of standard values is given for all imaging techniques.

5. A flow chart for the Emergency Room is designed to enhance efficacy of decision-making in acute aortic syndromes - survival is highly time-dependent.

6. Diagnostic steps and therapeutic options are described not only for aortic dissection, but also for intramural haematoma, penetrating aortic ulcer, and traumatic aortic injury.

7. The progress of interventional and vascular surgery required detailed discussion of AAA management to find the optimal time window for treatment and selection of endovascular or open surgery.

8. Hybrid Rooms have paved the way for developing new diagnostic and treatment options such as thoracic endovascular aortic repair [(T) EVAR], debranching aortic arch surgery, and the “frozen elephant trunk” technique.

9. New information on genetic and congenital aortic diseases with detailed recommendations, particularly for genetic testing.

10. We should now set up Aortic Teams and Centres to provide full access to specialists in cardiology, radiology, paediatric cardiology, genetics, aortic and vascular surgery, which are required not only for the acute but also for the intensive follow-up of patients with aortic diseases.

Guidelines on Acute Pulmonary Embolism. What is new? What has changed? by Stavros Konstantinides MD and Adam Torbicki MD

PE
Stavros Konstantinides
1. Assessment of hemodynamic stability of the patient and clinical probability of pulmonary embolism (PE) is the basis of all diagnostic strategies.

2. Appropriate use of D-dimer testing may reduce the need for unnecessary imaging and irradiation.

3. While computed tomographic (CT) angiography plays a key role in diagnostic algorithms, ventilation-perfusion (V/Q), compression venous ultrasonography (CUS) and emergency echocardiography may be helpful in management decisions.

4. Clinical assessment may identify patients at high risk (with shock or hypotension) requiring primary revascularization therapy, and patients at low risk of early death despite confirmed PE (PESI* classes I or II) who can be considered for early discharge if appropriately anticoagulated.

5. Among the remaining patients, those with signs of both right ventricular overload and positive humoral biomarkers (troponin, BNP) represent an intermediate-high risk group which should be monitored, as they may require rescue reperfusion therapy if clinical signs of haemodynamic decompensation appear.

6. Primary reperfusion treatment, particularly systemic thrombolysis, is the treatment of choice for patients with high-risk PE.

7. Surgical pulmonary embolectomy or percutaneous catheter-directed treatment are alternative methods of primary and rescue reperfusion treatment.

8. For most cases of acute PE without haemodynamic compromise, low molecular weight heparin (LMWH) or fondaparinux is the initial treatment of choice. Unfractionated heparin (UFH) should be used in hemodynamically unstable patients and those with severe renal dysfunction.

9. The non-vitamin-K-dependent oral anticoagulants (NOACs; direct inhibitors of factor Xa or thrombin) are non-inferior in terms of efficacy and possibly safer, particularly in terms of major bleeding, than the standard anticoagulation regimen consisting of heparin followed by a vitamin K antagonist (VKA).

10. Management of PE in patients with cancer and in pregnancy, duration of anticoagulation after initial episode, and management of patients with persisting symptoms and suspected/confirmed chronic thromboembolic pulmonary hypertension after PE, all require specific considerations and may need to follow separate recommendations – see guidelines.

*PESI = Pulmonary Embolism Severity Index

For more information see: http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/essential-message-slideset.aspx

EUROPEAN HEART JOURNAL SUPPLEMENT THE HEART OF THE MATTER

R Ferrari
Prof Ferrari
Credit: Sam Rogers
Cardiology is in constant evolution and the European Heart Journal Supplement (EHJs) has also changed.

Together with a group of excellent Associate Editors (Francisco Fernández-Aviles, Jeroen Bax, Michael Böhm, Frank Ruschitzka and Thomas Lüscher) an entirely new product has been developed the EHJs – the Heart of the Matter. The Editor-in-Chief is Prof Roberto Ferrari, Ferrara, Italy.

The EHJs – the Heart of the Matter intends to offer a service, not only to the usual sponsors but also to the ESC family, providing a dedicated, scientific space for the Affiliate Societies and, if needed, the National Societies, Associations, Working Groups and Councils the opportunity to disseminate their important successes to all of the 28,000 worldwide subscribers at a substantially reduced cost.

No matter how innovative a scientific journal is, its Impact Factor provides a numeric measure of its scientific value and success. The editorial staff are proud to report that the EHJs – the Heart of the Matter currently has an Impact Factor of 5.6 which is one of the highest for a similar journal.

The previous Editor, Francisco Fernandez-Aviles, is com

Further information is available through the ESC Journals webpage:

http://www.escardio.org/journals

TOUR DE COEUR - TOUR DIARY

Tour de Coeur - First report

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The "Tour de Coeur" started from Geneva, Switzerland for the fourth time. Thirty cardiovascular health professionals set off to bicycle to the Annual ESC Congress 2014 in Barcelona, Spain. The 1 week journey is to raise awareness for cardiovascular disease to reduce morbidity and mortality. It is also a fund raiser for the Swiss Heart Foundation to support cardiovascular research projects.

The group was sent off at Geneva University Hospital by Prof. François Mach, head of cardiology and was then accompanied to the French border by many friends and supporters on their bicycles.

The first stop at Lac d’Annecy provided a refreshing dip in the cool water. Their energy restored after a hearty picnic the journey continued along the River Rhone. They arrived at Albertville for the night after 112 km and 979 meters of altitude difference. It was rather a flat first leg.

The coming days will be much tougher with up to 2100 altitude meters to overcome!

Tour de Coeur - second day report

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Now in France the second stage of the “Tour de Coeur” is defined by high passes (Cols), best known from the Tour de France. First the group approached “Col de la Madeleine” 1993 m high with a long climb of 26 km. After refreshments, a long descent followed to la Chambre. Then, crossing over to the other side of the valley the ascent to the “Col du Glandon” began. One of the hardest passes in the Alps at 1483 m in only 22 km, there is a very steep last 3 km to the top. The scenery was great, the best part of the trip until now. A steep descent brought the riders down to Bourg d´Oisans.

Some of the hardier cyclists included the alp Huez, another 1860 m ascent with a difficult beginning. For them, it was a 150 km day with a total ascent of 4500 m. A really “great day” for the group!

Tour de Coeur third day, Peter Ferloni reports

After yesterday’s energy-sapping leg we would welcome a flat route like last year in Holland. But already, the Col d’Ornon rises like a giant wall in front of us. It’s raining, and after the first ascent at a temperature of only 9°C we start the descent.

Now the profile of the route resembles a malaria fever chart: up and down, on and on.

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But while it’s still raining and we are soaking wet, we get glimpses of the magnificent landscape, the craggy mountains, the deep ravines, the beautiful high valleys with their peaceful pine forests. And finally, we reach the day’s goal, our hotel in Gap. Exhausted but happy after 110 km and 2050 meters of altitude climbing we rest, dry our clothes and order an extra-large portion of pasta!

Our Facebook pages: https://www.facebook.com/schweizerischeherzstiftung (German)

https://www.facebook.com/FondationSuisseDeCardiologie (French)

Website: http://www.tourdecoeur.ch

Tour de Coeur fourth day, Philipp Haager reports

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Sunshine! After a day like yesterday, this word is wonderful.

We start with great alpine scenery, leaving Gap heading southwest down to the river Durance following Napoleon’s route. A powerful south wind made it hard to cycle. Slipstream was the magic word of the day.

We left the valley to the west and went uphill again through the wonderful and wild Canyon of Méouge. At the pass “Col de Macuégne”, we first saw the “Mont Ventoux”. The magic mountain that will be the highlight of the next day. We finished in Sault after 111 km and 1198 m total ascent.

https://www.facebook.com/schweizerischeherzstiftung (German)

https://www.facebook.com/FondationSuisseDeCardiologie (French).

Tour de Coeur Day 5, Philipp Haager reports

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A wonderful morning in the Provence: blue sky, warm and a smooth ascent up to the foothills of Mont Ventoux (1912m). We pass fields of lavender with its fantastic smell before entering into the pinewood forest. This is a capitol for biking: from every side come bikers and cyclists up to the top, like pearls on a pearl necklace!

A strong wind but also an incredible view of the Mediterranean Sea to the south and up to the Massif des Écrins with its snow covered peaks to the north!

Going downhill was a great run especially to enter the South of France summer. A wonderful 34° C awaited us after 99 km and a total climb of 1530m in Avignon.

Tour de Coeur Day 6, Philipp Haager reports

Day 6
After yesterday’s gorgeous day (day 5), we had to start early, to catch the TGV to Spain. We then hit the road again in Figueres. Of course, it started with a short shower of warm summer rain, but the temperature at 21o C was much more comfortable compared with Col de Ornon 3 days ago.

Small streets behind the coastline and a wonderful downhill sloping trail through olive groves, guided us to Peratallada.

We finished the day bathing in the sea after 82 km.

Tour de Coeur end

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After a week in the saddle, the team of 35 cycling Swiss cardiologists arrived on time in front of the Fira Gran Via on Saturday 30 August. Their 760 kilometre route from Geneva had crossed the famous Alpine passes of the Tour de France, all in aid of the Swiss Cardiology Foundation.

‘Fantastic,’ said Professor Hans Rickli. ‘Better to exercise than to talk about it.’