Updated ESC guidelines offer new recommendations on lipids, diabetes and more
PARIS — The European Society of Cardiology released five new guidelines, which introduce fresh recommendations such as an LDL goal of less than 55 mg/dL in patients at very high risk for CVD and the use of SGLT2 inhibitors and GLP-1 receptor agonists as first-line therapy in patients with diabetes requiring CVD prevention.
The guidelines, which also include recommendations on management of chronic coronary syndromes, pulmonary embolism and supraventricular tachycardia, were released at the ESC Congress and published in the European Heart Journal.
The new ESC guideline on dyslipidemias, produced in collaboration with the European Atherosclerosis Society, recommends that LDL be lowered as much as possible. Specifically, the document recommends a target of less than 55 mg/dL for patients with familial hypercholesterolemia, secondary prevention in high-risk patients with established CVD, and primary prevention in very high-risk patients without FH.
“There is now overwhelming evidence from experimental, epidemiological, genetic studies and randomized clinical trials, that higher LDL cholesterol is a potent cause of heart attack and stroke,” Colin Baigent, FRCP, chairperson of the guidelines task force and director of the MRC Population Health Research Unit at the University of Oxford, said in a press release. “Lowering LDL cholesterol reduces risk irrespective of the baseline concentration. It means that in people at very high risk of heart attack or stroke, reducing LDL cholesterol is effective even if they have below average starting levels.”
All patients treated with lipid-lowering therapy should attain at least a 50% relative reduction in LDL, the authors wrote.
“This is to ensure that high- or very high-risk patients receive intensive LDL cholesterol lowering therapy irrespective of their baseline level,” Alberico L. Catapano, PhD, chairperson of the guidelines task force and professor of pharmacology at the department of pharmacological and biomolecular sciences, University of Milan, Italy, said in the release. “Also, patients who are already on lipid-lowering therapy will be offered a treatment adjustment to provide a minimum 50% LDL-C reduction.”
The authors wrote that the benefits of statins far outweigh their risk, though these medications should not be used by pregnant women or premenopausal women who may become pregnant.
Statins may be considered in patients aged older than 75 years based on risk level, baseline LDL, health status and potential interaction with other drugs, according to the authors.
The document also recommends omega-3 fatty acids, particularly icosapent ethyl (Vascepa, Amarin), on top of statin therapy for patients with hypertriglyceridemia, and calls for lipoprotein(a) to be assessed at least once for all adults.
Diabetes and CVD
The guideline on diabetes, prediabetes and CVD, a collaboration with the European Association for the Study of Diabetes, elevates SGLT2 inhibitors and GLP-1 receptor agonists to first-line therapy in patients with diabetes who have CVD or are at high risk for it.
Metformin is now relegated to first-line therapy in patients with diabetes who are overweight and at moderate risk for CVD, Francesco Cosentino, MD, PhD, FESC, ESC chairperson of the guidelines task force and professor of cardiology at the Karolinska Institute and Karolinska University Hospital in Stockholm, Sweden, said in a press release.
The authors recommend lifestyle modifications for patients with prediabetes to prevent progression into diabetes and counsel against alcohol consumption.
“There has been a long-standing view that moderate alcohol intake has beneficial effects on the prevalence of cardiovascular disease,” Peter J. Grant, MD, FRCP, FMedSci, FESC, EASD chairperson of the guidelines task force and professor of medicine and honorary consultant physician, University of Leeds/Leeds Teaching Hospitals NHS Trust, Leeds Institute of Cardiovascular and Metabolic Medicine and LIGHT Laboratories, said the press release. “Two high-profile analyses have reported this is not the case and that alcohol consumption does not appear to be beneficial. On the basis of these new findings we changed our recommendations.”
Continuous self-monitoring of glucose is now recommended.
“It is no longer appropriate to depend on occasional glucose measures to manage control, particularly in type 1 diabetes,” Cosentino said in the release. “At the same time, flash technology has been developed which uses a small sensor worn on the skin to continuously monitor glucose levels. Similar arguments pertain to home blood pressure monitoring.”
Chronic coronary syndromes
The new ESC guideline on chronic coronary syndromes recognizes that stable CAD can be a dynamic condition and that noise and pollution can be particularly harmful to this population.
“Air pollution and environmental noise increase the risk of heart attack and stroke, so policies and regulations are needed to minimize both,” Juhani Knuuti, MD, PhD, FESC, chairperson of the guidelines task force and director of the Turku PET Centre, Finland, said in a press release. “Patients with chronic coronary syndromes should avoid areas with heavy traffic congestion and may consider wearing a respirator face mask. Air purifiers with high efficiency particulate air filters can be used to reduce indoor pollution.”
The new document supports cognitive behavioral therapy and cardiac rehabilitation in this population and emphasizes lifestyle modification — including smoking cessation; avoiding secondhand smoke; eating a diet high in vegetables, fruits and whole grains and low in saturated fat and alcohol; maintaining a healthy body weight; and exercising regularly — more than its predecessor.
The guideline on acute PE, produced in conjunction with the European Respiratory Society, clarifies the diagnostic process, advising clinicians to first consider symptoms and blood test before moving to CT or ultrasound if necessary.
“The aim is to get to the diagnosis as reliably and quickly as possible, in order to start lifesaving therapy and prevent other clots from reaching the lungs,” Guy Meyer, MD, PhD, cochairperson of the guidelines task force and respiratory medicine physician, Hôpital Européen Georges-Pompidou, Paris, said in the release.
The document recommends anticoagulants for patients with confirmed acute PE and clot removal with thrombolytic drugs, catheter-based procedures or surgery if a patient with acute PE is in shock.
The ESC’s new guideline on management of supraventricular tachycardia recommends antiarrhythmic drugs for acute episodes but not long-term therapy.
Because of new technologies, catheter ablation to treat supraventricular tachycardia is now recommended more strongly than previously, and is the preferred treatment over antiarrhythmic drugs in pregnant women.
“Catheter ablation techniques and technology have evolved in a way that we can now offer this treatment modality to most of our patients with SVT,” Demosthenes Katritsis, MD, PhD, FRCP, FESC, FACC, chairperson of the guidelines task force and director of the 3rd cardiology department, Hygeia Hospital, Athens, said in a press release. – by Erik Swain
Windecker S, et al. 2019 ESC Guidelines Overview. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019; Paris.
Disclosures: Baigent, Catapano, Cosentino, Grant, Katritsis, Knuuti and Meyer report no relevant financial disclosures.