Four separate clinical guidelines were released by the European Society of Cardiology (ESC) as part of ESC Congress 2023 addressing the management of acute coronary syndromes (ACS), cardiomyopathies, type 2 diabetes (T2D) and infective endocarditis. Also published was a focused update of the ESC heart failure (HF) guideline.

The ESC guideline on ACS covers the management of unstable angina and all types of acute myocardial infarction (MI) and provides detailed advice on treatment, including use of anticoagulants and antiplatelets; when to perform radial vs. femoral catheterization; and options when there is no complete blockage, or when patients are in geographically remote areas.

It also addresses the crucial nature of long-term management to reduce the risk of repeat events, including aggressive control of cholesterol levels, use of medications like antiplatelets, and participation in supervised cardiac rehabilitation programs. The guideline includes new sections on managing ACS in patients with cancer, as well as ensuring patient perspectives inform clinical decisions.

The ESC guideline on cardiomyopathies includes all cardiomyopathy (CM) subtypes and marks the first time that specific recommendations are made for CMs other than hypertrophic CM. It highlights the many areas of diagnosis and management shared across CM subtypes and provides specific recommendations, including use of shared decision-making and multidisciplinary teams, for managing each.

Of note, the guideline provides recommendations on the use of imaging techniques, such as echocardiography and CMR imaging, for diagnosing certain CM subtypes and for identifying patients at risk of sudden cardiac death (SCD).

Genetic counseling is recommended to support patients and their families in understanding the disease and clinical psychological support encouraged for all patients who have undergone ICD implantation or who have a family history of SCD. A dedicated section provides specific advice for patients living with CM, including urging low to moderate exercising for those able to do so, healthy diets, vaccination and more.

In the ESC guideline for the management of cardiovascular disease in patients with T2D, lifestyle changes, including weight reduction, daily exercise, smoking cessation and diet, are recommended to reduce the likelihood of cardiovascular disease. In addition, recommendations for patients with T2D and existing cardiovascular disease have been revised following the results of several large clinical trials.

For example, the guideline now recommends SGLT2 inhibitors and/or GLP-1 receptor agonists to reduce the risk of MI and stroke in all patients with T2D and cardiovascular disease, independent of glucose control and concomitant glucose medication, and in addition to standard of care antiplatelet, antihypertensive and lipid-lowering therapies.

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Managing HF is a special focus given the two- to four-fold greater risk of developing HF in patients with vs. without diabetes. Specifically, the guideline recommends screening for HF signs and symptoms during each clinical encounter to allow early detection and treatment. Annual screening for chronic kidney disease (CKD) is also recommended.

For the first time, the guideline recommends opportunistic screening for atrial fibrillation by pulse taking or electrocardiogram in patients with T2D ≥65 years old, and in patients <65 when other risk factors such as high blood pressure (BP) are present. Also new is a recommendation for regular BP measurements in all patients with T2D to detect and treat hypertension and reduce the risk of cardiovascular disease.

The new ESC guideline on infective endocarditis recommends that patients with specific cardiac conditions such as valvular heart disease and congenital abnormalities, or those requiring a pacemaker, practice good dental and skin hygiene to help prevent the rare but potentially deadly infections of the heart's inner lining and valves.

This means twice daily teeth cleaning, professional dental cleaning (twice yearly for high-risk and yearly for intermediate-risk patients), strict skin hygiene and treatment of chronic skin conditions, and avoiding piercings and tattoos.

Recommendations are also provided for diagnosis, treatment and management of complications including stroke. The guideline addresses when to use echocardiography, CT, nuclear imaging and MR imaging plus novel diagnostic algorithms when the infection involves native heart valves, prosthetic heart valves and implanted cardiac devices.

Additionally, a new section of the guideline is devoted to patient-centered care and shared decision-making.

For the focused update of the ESC guideline for HF, the authors took into account results of major new clinical trials like STRONG-HF that are changing how patients are being managed before, during and after discharge.

For example, the new document recommends an intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge and during frequent and careful follow-up visits in the first six weeks after hospitalization for HF to reduce readmission and mortality.

Additionally, the update stresses the need for clinicians to pay close attention to symptoms and signs of congestion, BP, heart rate, NT-proBNP plasma concentrations, potassium concentrations and estimated glomerular filtration rate during follow-up, as these factors are linked with prognosis and can signal the need for further changes in treatment.

The focused update also provides two new recommendations for the prevention of HF in patients with CKD and T2D as well as provides guidance on the use of intravenous iron supplementation to help address iron deficiency in patients with HF with reduced ejection fraction.