The European Society of Cardiology (ESC) has released three new sets of updated guidelines in three areas of cardiovascular care: STEMI patients; acute and chronic heart failure; and the management of acute pulmonary embolism during their annual congress, which took place in Munich, Germany, this week.
Compared to the 2003 guidelines, a specialized task force published new recommendations regarding care for patients with STEMI, including:
- The need for setting up networks of hospitals with different levels of technology using the same protocol and connected by an efficient ambulance service;
- The selection of primary PCI versus fibrinolytic therapy;
- The use of antithrombotic co-therapies with both primary PCI and fibrinolytis; and
- Secondary prevention.
The STEMI task force said it intends to put these guidelines on the website of the ESC and the European Heart Journal within a few weeks.
Heart failure implementation guidelines
For heart failure implementation, a task force of 15 experts in the field and a review committee of 21 international authorities have developed guidelines that cover both acute and chronic heart failure for the first time.
The guidelines have built upon the realization that patients with acute heart failure often develop chronic problems and likewise, those with chronic heart failure, often suffer from acute illness.
The new guidelines review diagnostic techniques, both pharmaceutical and device therapies, as well as non-pharmacological management. Unlike past guidelines, the 2008 document places greater emphasis on the importance of implementing treatment recommendations and management of palliative care. The document also summarizes the major “gaps in evidence” in an attempt to focus future clinical research on important issues that have not been adequately addressed. As such, the guidelines addresses issues that cardiologists are aware of, but do not have evidence for.
The 2008 guidelines were launched at the congress on Sept. 1, and the full text will be published in the European Heart Journal and the European Journal of Heart Failure.
Acute pulmonary embolism management guidelines
The first edition of the ESC Clinical Practice Guidelines on the management of acute pulmonary embolism (PE) was published in 2000. The 2008 update focuses on:
- Currently available and validated methods of diagnosis;
- Prognostic evaluation;
- Therapy of PE; and
- Management in specific situations, such as pregnancy.
In contrast to previous PE guidelines, the authors graded the body of evidence supporting both treatment and diagnostic procedures, because the latter are of particular importance in the management of PE.
Another section is devoted to prognostic assessment of PE by reviewing and grading the clinical, ultrasound and laboratory findings, which allow the estimation of death and complication risk during the early, in-hospital phase of the disease, according to the authors. The assessment and the classification of PE into high-risk, low-risk and intermediate-risk is particularly useful for guiding treatment strategies which are reviewed in the next section of the guideline, such as the use of thrombolytic drugs or blood thing.
The guideline recommends the use of blood thinners (secondary prevention) for variable periods of time after an episode of PE, depending on the patient's risk of recurrence. In contrast to the two risk categories, treatment remains controversial in patients with intermediate-risk PE, that is patients who present with normal blood pressure but with ultrasound and laboratory findings which indicate beginning heart failure.
A large European trial is currently underway to determine whether these patients need clot busters (like the high-risk category) or can be managed with blood thinners alone (like the low-risk category).
The trial, PEITHO (Pulmonary Embolism International Thrombolysis Study), is a European investigator-initiated and investigator-sponsored study that is also supported by funds from the French and German governments. The study began in early 2008 and already recruited patients in six countries: France, Italy, Germany, Poland, Switzerland, Slovenia. A total of 64 patients have been enrolled so far. Another six countries will be initiated soon. The study plans to randomize as many as 1,000 patients until the end of 2010.