During the European Society of Cardiology (ESC) congress, which took place this year in digital version, four new guidelines were presented. The papers, which were simultaneously published in the European Heart Journal and on the company’s website, cover adult congenital heart disease, treatment of acute coronary syndrome without ST-segment elevation, atrial fibrillation and sports practice for patients with cardiovascular disease.
Four new ESC guidelines 2020: congenital heart disease in adults
The first updated version of the guidelines is addressed to adult patients with congenital heart disease. The news are many, here are some of those reported in the document.
Regarding patients with Eisenmenger syndrome and pulmonary arterial hypertension, the guidelines recommend that patients with congenital heart disease and confirmed pre-capillary pulmonary hypertension are counselled against pregnancy. In addition, a risk assessment is recommended in all patients with pulmonary hypertension and congenital heart disease. In low- and intermediate-risk patients with simple repaired lesions and pre-capillary pulmonary hypertension, initial combined oral or sequential therapy is recommended. High-risk patients should be treated with initial combination therapy including parenteral prostanoids.
In patients with shunt lesions and signs of non-invasive evaluation of an increase in pulmonary arterial pressure, invasive measurement of pulmonary vascular resistance becomes mandatory.
Another novelty, in patients with atrial septal defects, is the recommendation to perform the balloon test and carefully evaluate the benefit of shunt elimination, versus the potential negative impact of defect closure on outcome due to increase in filling pressure (taking closure, fenestrated closure, and no closure into consideration).
Finally, surgery is recommended in patients with an abnormal origin of coronary artery disease and typical angina symptoms who present with evidence of stress-induced myocardial ischaemia in a matching territory or high-risk anatomy.
Four new ESC guidelines 2020: atrial fibrillation
Let’s now look at the most important new recommendations introduced in the 2020 guidelines on atrial fibrillation.
While it may seem trivial, it was established that ECG documentation is required to reach the diagnosis of atrial fibrillation. More precisely, the diagnosis is made when a heart rhythm without recognizable repetitive P waves and irregular RR intervals for 30 or more seconds is observed.
Regarding the prevention of thromboembolic events, a Class I recommendation was introduced to reassess the risk of stroke and bleeding at periodic intervals to better target treatment decisions and act on potentially modifiable bleeding risk factors.
A new recommendation appears on cardioversion, in class I, which considers it indication only in haemodynamically stable patients, after considering the thromboembolic risk.
Regarding anticoagulant treatment in patients undergoing a catheter ablation procedure of atrial fibrillation, a new recommendation, in class I, states that patients who have been anticoagulated with warfarin, dabigatran, rivaroxaban, apixaban or edoxaban, should not stop the treatment.
Another new recommendation states that patients with atrial fibrillation and acute coronary syndrome who undergo uncomplicated catheter revascularization should stop aspirin early (≤ 1 week) and continue dual therapy with an oral anticoagulant and a P2Y12 inhibitor, preferably clopidogrel, for up to 12 months if the risk of stent thrombosis is low or if concerns about bleeding risk prevail over concerns about risk of stent thrombosis, irrespective of the type of stent used.
Four new ESC guidelines: the treatment of acute coronary syndrome without ST-segment elevation
In the area of coronary heart disease, new guidelines have been presented for the treatment of acute coronary syndrome without ST segment elevation.
In this new document there are many innovations. The new recommendations in class I include, among others, indications for the management of antithrombotic treatments. As recommended by the atrial fibrillation guidelines, in patients with this arrhythmia (CHA2DS2-VASc score ≥ 1 in men and ≥ 2 in women), after a short period of triple antithrombotic therapy (up to 1 week after the acute event), dual antithrombotic therapy is recommended as a default strategy, using a direct anticoagulant and a single oral antiplatelet agent (preferably clopidogrel).
Regarding treatment, a new class I recommendation endorses an early invasive strategy within 24 hours in patients with one of the following high-risk criteria: diagnosis of NSTEMI, dynamic or presumably new changes in the contiguous ST / T segment suggesting an ongoing ischaemia, transient ST segment elevation, GRACE risk score> 140.
Also, in class I, a selective invasive strategy is recommended, after an appropriate test for inducible ischemia or the detection of obstructive coronary heart disease by coronary CT scan, in patients considered to be at low risk.
Still about coronary CT scan, there is a transition from class IIa to class I and the substantial change of a recommendation concerning it. The 2015 edition of the guidelines indicated that coronary CT scan “should be” considered as an alternative to invasive angiography to rule out acute coronary syndrome, when there is a low to intermediate probability of coronary heart disease and when cardiac troponin and / or ECGs are normal or inconclusive. In the 2020 edition of the guidelines, the coronary CT scan in the afore mentioned conditions is instead “recommended”.
Four new ESC guidelines: sport and physical activity in the heart patient
The document published in the 2020 edition concerns the guidelines dedicated to the management of exercise and sports activity in patients with cardiovascular diseases.
The recommendations in this area were initially published by the Sports Cardiology Section of the ESC in 2005, with subsequent updates in 2018 and 2019.
The document begins by specifying that most of the population practice leisure sports and recreational physical activity and, unlike elite athletes, have a higher prevalence of risk factors for atherosclerosis and cardiovascular disease.
The guidelines continue with advice on risk stratification in individuals participating in recreational and competitive sports. Here, a chapter is dedicated to screening in older subjects (> 35 years).
Each sport is then characterized on the basis of the characteristic components and the physical effort required, indicating precise indices of exercise intensity for endurance sports, derived from the maximal effort test, in the respective training areas (aerobic, aerobic + lactate, anaerobic).
Among the recommendations presented in the document, in obese individuals (BMI ≥ 30 kg / m2 or a waist circumference> 80 cm for females or> 94 cm for males) resistance training ≥ 3 times per week is recommended, in addition to moderate or intense aerobic exercise (at least 30 min, 5-7 days a week) to reduce the risk of cardiovascular.
In individuals with well-controlled hypertension, resistance training ≥ 3 times per week is recommended, in addition to moderate or intense aerobic exercise (at least 30 min, 5-7 days per week) to reduce blood pressure and cardiovascular risk.
In patients with diabetes mellitus, resistance training ≥ 3 times per week is recommended, as well as moderate or intense aerobic exercise (at least 30 min, 5-7 days per week) to improve insulin sensitivity and achieve a better cardiovascular risk.
The document continues with targeted advice in specific clinical contexts and ends with a useful synoptic table with information on “What to do” and “what not to do” in sport.
Here the link to the four new guidelines ESC
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