New ESC Guidelines Focus on STEMI, Valvular Heart Disease and AFib
Two new ESC guidelines and one focused update were released as part of the ESC Congress 2012 in Munich on Aug. 25. The two guidelines focus on the management of acute myocardial infarction (MI) in patients presenting with ST-segment elevation, and the management of valvular heart disease, respectively, while the focused update provides new guidance on the management of atrial fibrillation (AFib).
Timely diagnosis and treatment of STEMI is central to the new recommendations for management of acute MI patients. The new guideline includes a recommendation that centers equipped to perform primary PCI should deliver care on a 24/7 basis and within 60 minutes of an initial call. The guideline also notes that ambulance teams should be trained and able to identify patients with STEMI and administer initial therapy, including fibrinolysis if applicable.
The guideline also highlights the importance of regional networks, which include the ambulance service and the cath lab, that are designed to deliver reperfusion therapy quickly and effectively.
Key time targets set by the guidelines include:
- First medical contact (FMC) to ECG - no longer than 10 minutes
- FMC to fibrinolysis - no longer than 30 minutes
- FMC to primary PCI - no longer than 90 minutes (or one hour if patient presents in a PCI-able hospital, or within two hours of onset or has large area at risk)
Also of note: Reperfusion therapy is recommended for all STEMI patients within 12 hours of first symptoms, and beyond this 12-hour window only if there is persistent or stuttering pain and ECG changes. Clopidogrel and aspirin are recommended for fibrinolysis, and dual antiplatelet therapy for up to 12 months in those having primary PCI, with a strict minimum of one month for those receiving a bare-metal stent and six months a drug-eluting stent.
Valvular Heart Disease
The new ESC guidelines for valvular heart disease emphasize an overall "heart team" approach to treatment, which includes cardiologists, cardiac surgeons, imaging specialists, anaesthetists and others if needed in the decision-making process.
The guidelines also make several recommendations related to the newly emerging transcatheter aortic valve implantation (TAVI). They recommend TAVI only "in hospitals with cardiac surgery on-site" and with a heart team available to assess individual patient risks. The guidelines also emphasize that, at present, TAVI should not be performed in patients at intermediate risk for surgery, for which no supporting data are currently available.
In mitral regurgitation, the second most frequent valve disease requiring surgery, the task force states that mitral valve repair should be the preferred approach when the repair is considered durable. Thus, it is important to increase surgical expertise and the number of reference centres. The guideline task force also notes that percutaneous mitral valve repair using the edge-to-edge technique (Mitraclip) may be considered in high-risk or inoperable patients refractory to optimal medical management with the aim of improving symptoms. However, the authors stress that longer follow-up is needed as well randomized clinical trials
AFib Focused Update
Among the AFib focused update's new additions are the application of the CHA2DS2DS2-VASc score instead of the CHADS2 score for identifying patients at risk of stroke and the use of new oral anticoagulants as a preferred alternative to vitamin K antagonists.
The new update also states that the evidence supporting use of aspirin in stroke prevention is weak, with a high risk of bleeding in elderly AFib patients. It suggests restricting aspirin use to patients who refuse anticoagulation. According to the focused update authors, the new anticoagulants have "all shown non-inferiority compared with [vitamin K antagonists], with better safety" in clinical trials. As a result, they are "broadly preferable" in the vast majority of patients with non-valvular AFib within the context of "strict adherence to approved indications."
Also of note, the update introduces vernakalant as a new drug for the rapid cardioversion of recent onset AFib applicable to a broad range of patients with some exceptions. The update also addresses rhythm control with antiarrhythmic drugs and left atrial ablation, according to John Camm, MD, chair of the development task force and professor at St. George's Hospital, London. The use of dronedarone is not recommended in patients with permanent AFib or with moderate or severe heart failure and its use is relegated to a therapy of last resort for patients even with mild heart failure. However, catheter ablation is given a strong recommendation for patients with paroxysmal AFib and little or no atrial remodeling provided it is conducted by experienced operators, and its use as a first-line therapy is also endorsed in similar circumstances.
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