The European Society of Cardiology (ESC) released two separate guidelines addressing the management of dyslipidemia and the treatment of atrial fibrillation (AFib) as part ESC Congress 2016 in Rome. A cardio-oncology position paper addressing the cardiac toxicity of anticancer therapies was also released. All three clinical documents were simultaneously published in the European Heart Journal.

The new ESC and European Atherosclerosis Society (EAS) dyslipidemia guidelines stress the need to lower lipid levels in populations and in high-risk individuals. They recommend combination treatment (ezetimibe and a statin) in patients with resistant high cholesterol. Unlike U.S. guidelines that recommend a statin for all high-risk patients – even those with low cholesterol – the ESC/EAS guidelines recommend an individual LDL cholesterol target based on risk (defined by comorbidities and 10-year risk of fatal cardiovascular disease). They also recommend that all patients, regardless of risk, should achieve a minimum 50 percent reduction in LDL cholesterol.

“The American approach would mean considerably more people in Europe being on a statin,” said Ian Graham, MD, chair of the ESC Task Force. “The Task Force decided against this blanket approach. The worry is that a large population of high-risk people who are inert and overweight have their cholesterol lowered by drugs but then ignore their other risk factors.”

The guidelines also address PCSK9 inhibitors, noting they can be considered in patients with persistent high LDL cholesterol on a statin and ezetimibe. “The PCSK9 inhibitors have a substantial effect over and above maximum therapy and are a real advance for patients with severe familial hypercholesterolemia, for example,” said Alberico Catapano, MD, chair of the EAS Task Force. “However, they are extremely expensive and therefore their use may be limited in some countries.”

Additionally, the guidelines give more prominence to lifestyle and nutrition than previous guidelines, with goals for body mass index and weight. Recommendations are given for foods to be preferred, used in moderation, or chosen occasionally in limited amounts. The guidelines no longer require fasting before screening for lipid levels, given new evidence that non-fasting blood samples give similar cholesterol results.

AFib Guidelines

The ESC guidelines on AFib developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) and endorsed by the European Stroke Organisation recommend non-vitamin K antagonists oral anticoagulants (NOACs) as the first line anticoagulant in eligible patients. However, vitamin K antagonists, namely warfarin, remain a valid treatment for stroke prevention in AFib and should be the first choice in patients ineligible for NOACs, such as those with mechanical heart valves.

The guidelines recommend what to do when patients develop complications on anticoagulation, including re-initiation of anticoagulation treatment after a bleed, how to manage bleeds, and how to manage patients who have an ischemic stroke while on anticoagulation. Greater emphasis is also placed on the early diagnosis of AFib, before the first stroke, including use of opportunistic and targeted electrocardiogram screening in people over 65 years of age and in high-risk groups such as patients with pacemakers.

“Previous guidelines focused on which patients should receive anticoagulation and that issue is largely settled,” said Paulus Kirchhof, MD, chair of the ESC Task Force. “The new guidelines also address the long-term challenges in anticoagulated [AFib] patients that all too often lead to discontinuation of anticoagulant therapy despite prognostic benefits in the long term.”

Cardio-Oncology Position Paper

A novel new position paper on cardio-oncology developed by the ESC Committee for Practice Guidelines reviews cardiovascular complications of anticancer therapy. The paper focuses on nine categories: myocardial dysfunction and heart failure (HF); coronary artery disease; valvular disease; arrhythmias; arterial hypertension; thromboembolic disease; peripheral vascular disease and stroke; pulmonary hypertension; and pericardial complications.

For each type of complication, the authors outline which patients are at risk, how to detect and prevent possible side effects, and how to treat and follow up with patients.

For example, coadministration of anthracyclines and trastuzumab in patients with breast cancer markedly increases the incidence of HF. But cardiotoxicity can be reduced significantly by introducing a drug-free interval between the two agents.

The paper also emphasises the importance of establishing multidisciplinary teams that include cardiologists, oncologists, nurses, and HF and imaging specialists to provide the best care for cancer patients and survivors. The authors note that ultimately structured cardio-oncology centers are needed.

“We hope the paper will increase awareness about heart disease in cancer patients and survivors and stimulate more research in this area,” said Committee Co-Chair Patrizio Lancellotti, MD, FACC. “More information is needed on when to screen and monitor patients, and on the cardiovascular effects of new anticancer therapies.” 

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardio-Oncology, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Homozygous Familial Hypercholesterolemia, Lipid Metabolism, Nonstatins, Primary Hyperlipidemia, Acute Heart Failure, Pulmonary Hypertension, Hypertension

Keywords: ESC Congress, Atrial Fibrillation, Anthracyclines, Anticoagulants, Atherosclerosis, Body Mass Index, Cholesterol, Cholesterol, LDL, Comorbidity, Coronary Artery Disease, Heart Failure, Heart Valves, Hypercholesterolemia, Hyperlipoproteinemia Type II, Hypertension, Pulmonary, Incidence, Life Style, Overweight, Peripheral Vascular Diseases, Vitamin K, Warfarin, Cardiotoxicity

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