ESC Streamlines Cardiovascular Guidelines | MedPage Today

LONDON — A set of new European guidelines streamlined recommendations for atrial fibrillation (Afib), chronic coronary disease, peripheral artery disease (PAD) and aortic disease, and hypertension, with an emphasis on shared decision-making and implementation.

A session at the European Society of Cardiology (ESC) meeting highlighted new aspects of the guideline updates released online in the European Heart Journal.

“There’s so much undertreatment in atrial fibrillation, so much undertreatment in PAD, and even with chronic coronary syndromes,” commented Roxana Mehran, MD, of the Icahn School of Medicine at Mount Sinai in New York City. “I think simplifying things and bringing it to a point of allowing us to make diagnosis easier and to move ahead and maybe be more aggressive on our medical management of these patients, I’m really pleased to see those [changes].”

Chronic Coronary Syndromes

The guideline introduced a new definition for chronic coronary syndromes in keeping with the recent paradigm shift from understanding it as stenosis causing myocardial ischemia, to the now more dynamic concept of coronary microvascular dysfunction that, alongside stenosis in the epicardial coronary artery and vasomotor disturbances, leads to the development of myocardial ischemia and to chronic coronary syndromes.

“You may think these are rarities, but in every patient you see these mechanisms can be present,” said guideline co-chair Christiaan Vrints, MD, PhD, of Antwerp University Hospital in Belgium.

The major novelty in diagnosis recommendations was a new risk factor-weighted likelihood model for pretest probability of obstructive coronary artery disease to replace the prior model that significantly overestimated risk, he said, and avoids additional testing in a lot of patients. Also, exercise testing was recommended only for assessing prognosis and adjusting likelihood rather than diagnosis.

“The biggest thing for me was seeing the class 1 recommendations that were new, especially with regard to intravascular imaging and physiology, both extremely great and long time coming,” commented Mehran, noting that U.S. guidelines “still don’t have class 1 recommendation for physiology and imaging, but I believe that is hopefully coming.”

For the many patients without obstructive disease, you have to think angina or ischemia with non-obstructive coronary arteries, said Vrints.

Antithrombotic therapy was updated to allow for the combination of aspirin and a strong P2Y₁₂ inhibitor in certain high-thrombotic-risk conditions like left main bifurcation, chronic total occlusion, and genetic prothrombotic genotypes; for clopidogrel as an alternative to aspirin in long-term single-antiplatelet therapy; and for aspirin in patients with significant coronary artery disease, even in those who do not have a prior history of myocardial infarction. The guideline also strengthened the recommendation for short dual-antiplatelet therapy in patients with high bleeding risk.

In terms of tackling residual risk, the guideline pointed to GLP-1 drugs for patients with obesity and colchicine for reduction of inflammation, which Mehran called a “really exciting” change.

Afib

The update emphasized integrated Afib care, first and most importantly treating comorbidities and risk factors in paroxysmal cases before tackling stroke risk reduction.

Selecting patients for anticoagulation for stroke risk reduction now has a class 1 recommendation for a simplified tool, the CHA₂DS₂-VASc score, and the guideline recommended against use of a bleeding risk score to start or withdraw anticoagulation.

In terms of treatment, ablation is now first line in paroxysmal Afib, and endoscopic or hybrid treatment has a class IIa recommendation for persistent Afib despite antiarrhythmic drug use.

The recommendations also emphasized reassessing patients in a dynamic way for how their Afib and comorbidities are changing, which could be as simple as putting the direct oral anticoagulant back to full dose after acute kidney injury has resolved.

PAD and Aortic Diseases

For the first time, the ESC combined these two arterial systems in the same guideline to make the point that they are part of one unique vascular system, said guideline chair Lucia Mazzolai, MD, PhD, of Lausanne University Hospital in Switzerland. One affects the other and they share common risk factors and management, so patients need to be globally assessed, she added.

Simplified classification into three clinical presentation groups was introduced for PAD: asymptomatic, symptomatic with exertion, and chronic limb-threatening ischemia.

A new recommendation was against revascularization for asymptomatic PAD; for symptomatic cases, it was recommended only after a period of supervised exercise training and optimal medical therapy, and in a multidisciplinary setting.

Along with new PAD recommendations for lipid-lowering and antithrombotic therapy, the guidelines called for at least annual follow-up.

There was also standardization of measurements and nomenclature for aortic disease and recommendation for CT and cardiac MRI use depending on availability and expertise.

“Most of our decisions are going to be made based on the diameter in a specific region of the aorta,” said co-chair José F. Rodríguez-Palomares, MD, PhD, of Universitat Autònoma de Barcelona, “so it is very important for all of us to use the same nomenclature. It is very important for all of us to use the same methodology in measurement in order to have consistency in our communication.”

Along with a number of surgery and endovascular procedure recommendations for aortic root and ascending aorta dilatation, the guideline offered an algorithm to help reduce delays in diagnosis and referral to an expert center and an easy medication management algorithm.

Hypertension

These guidelines streamlined the diagnostic categories into just three: hypertension (140/90 mm Hg or greater), elevated (120-139/70-89 mm Hg), and non-elevated (less than 120/70 mm Hg). They also put more emphasis than before on out-of-office measurement for both diagnosis and management and provided equivalents to in-office measurements.

New and highlighted in the recommendations was that patients with hypertension should increase potassium intake. “There’s now a lot of evidence to indicate, indeed, that increasing potassium intake, particularly in patients with hypertension without moderate to advanced kidney disease, is really what should be focused upon,” said guideline co-chair Rhian Touyz, MBBCh, PhD, of McGill University in Montreal. “And this increase in potassium intake should be in the form of sodium-substitution salt and/or a high potassium diet such as the DASH diet or the Mediterranean diet.”

New recommendations in treatment were to start with combination therapy for hypertension and treat to a target of 120-129 mm Hg within 3 months, or to “as low as reasonably achievable” if not feasible due to poor tolerance.

For resistant hypertension uncontrolled despite medication intensification, renal denervation was included as an option under shared decision-making and when performed at a medium- to high-volume center.