ESC 2022 Highlights Include Inaugural Cardio–Oncology Guidance

The European Society of Cardiology Published Four Guidelines at its Annual Congress in August 2022, Including its First Set of Cardio–Oncology Guidance. Guidelines in Practice Assesses the Recommendations in Each

Introduction

The 2022 Congress of the European Society of Cardiology (ESC) took place in Barcelona from 26–29 August. In addition to the usual hot line and late-breaking trials sessions, the conference also featured the publication of four sets of guidance. These covered the management of patients with ventricular arrythmias and the prevention of sudden cardiac death,¹ the diagnosis and treatment of pulmonary hypertension,² the cardiovascular assessment and management of patients undergoing non-cardiac surgery,³ and new guidelines on cardio–oncology.⁴   

Get the Balance Right in Cardio–Oncology

Cardiovascular and cancer care are both prioritised in the NHS Long Term Plan,⁵ and the ESC has now published its first set of guidance for healthcare professionals who provide care to oncology patients with respect to their cardiovascular health and wellness before, during, and after cancer treatment.⁴ The new recommendations provide guidance on the definitions, diagnosis, treatment, and prevention of cancer therapy-related cardiovascular toxicity, and the management of cardiovascular disease caused either directly or indirectly by cancer.

The guidance contains 272 recommendations, with an emphasis on the need to balance the most permissible (from a cardiovascular disease perspective) with the most effective (from an oncological perspective) cancer treatment.⁴ It provides:

• a new international definition of cancer treatment-related cardiovascular toxicity
• detailed monitoring pathways for specific cancer therapies to detect cardiovascular toxicity risk
• guidance on continuing trastuzumab in breast cancer patients who develop asymptomatic moderate cancer therapy-related cardiac dysfunction (left ventricular ejection fraction 40–49%) while initiating cardioprotective medication
• a structured algorithm to guide decisions regarding anticoagulation management in patients with cancer presenting with atrial fibrillation or venous thromboembolism
• an algorithm for cancer survivors who are stopping cardiovascular medication.⁴

Other key points include:

• integration is a guiding principle of cardio–oncology; cardio–oncology providers must have knowledge of the broad scope of cardiology, oncology, and haematology, and communication between different healthcare professionals is critical to optimise patient care
• cardio–oncology programmes minimise unnecessary interruptions to cancer treatment, as well as cancer therapy-related cardiovascular toxicity
• multidisciplinary team discussion should balance the risks and benefits of stopping cancer treatment for patients who develop cardiovascular toxicity
• baseline cardiovascular risk assessment is recommended for all patients with cancer who are due to receive a potentially cardiotoxic anticancer therapy
• measures are needed for both primary and secondary prevention of cardiovascular toxicity
• a cardio–oncology team must coordinate long-term follow-up of cardiovascular toxicity risk and surveillance planning once cancer therapy has finished
• patients and their carers should be provided with guidance to promote healthy lifestyle and to recognise and report signs and symptoms of cardiovascular disease.⁴

The guideline committee pointed out that, due to ‘the fast-moving pace of new oncology treatment developments against a background of dynamic cardiovascular toxicity likelihood’, more randomised controlled trials to guide decision-making were needed, as well as ‘strategic investments in cardio–oncology care networks and cardio–oncology services provision’ to meet the projected increased clinical demand in the near future.⁴

Pulmonary Hypertension Guidance Updated

In association with the European Respiratory Society (ERS), the ESC has updated its guidelines for the diagnosis and treatment of pulmonary hypertension.² The ESC/ERS guidelines were developed by a multidisciplinary task force that included cardiologists, pneumologists, a thoracic surgeon, methodologists, and patients, in response to progress made in recent years in the detection and management of pulmonary hypertension.

The 2022 guidelines have an emphasis on diagnosing and treating pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (CTEPH).² Changes to the guidelines include:

• the haemodynamic definition of pulmonary hypertension has been amended to a mean pulmonary arterial pressure (mPAP) >20 mmHg
• pulmonary arterial hypertension is defined as a pulmonary vascular resistance greater than 2 WU, and a pulmonary arterial wedge pressure ≤15 mmHg
• the main diagnostic algorithm for pulmonary hypertension has been simplified to a three-step approach consisting of:
  • suspicion by first-line physicians
  • detection by echocardiography
  • confirmation with right heart catheterisation in pulmonary hypertension centres
• a recommendation for expedited referral for high-risk or complex patients
• screening strategies for pulmonary arterial hypertension in patients with scleroderma and in patients at risk of heritable pulmonary arterial hypertension to shorten the time from symptom onset to diagnosis of pulmonary arterial hypertension
• enhanced recognition of computed tomography and echocardiographic signs at the time of acute pulmonary embolism, along with a systematic follow-up of patients with acute pulmonary embolism, to improve underdiagnosis of CTEPH
• echocardiographic and cardiac magnetic resonance imaging criteria have been added to the risk-stratification table, refining non-invasive evaluation at diagnosis
• a four-strata risk stratification for intermediate-risk patients
• the pulmonary arterial hypertension treatment algorithm has been simplified, highlighting the importance of cardiopulmonary comorbidities, risk assessment both at diagnosis and at follow-up, and the importance of combination therapies
• the treatment algorithm for CTEPH has been modified, including multimodal therapy with surgery, drugs, and balloon pulmonary angioplasty
• supervised exercise training is now recommended in patients with pulmonary arterial hypertension under medical therapy.²

Ventricular Arrhythmias Guidance Incorporates Latest Evidence  

Updated from the 2015 ESC guidelines for the management of patients with ventricular arrhythmias (VA) and the prevention of sudden cardiac death (SCD), the 2022 guidance offers new insights into the epidemiology of SCD, new evidence on genetics, imaging, and clinical findings for risk stratification for VA and SCD, and advances in diagnostic evaluation and therapeutic strategies.¹

Key points in the guidance include:

• genetic testing should be a routine part of care for patients with genetic cardiomyopathies and arrhythmia syndromes
• a comprehensive autopsy is recommended in all cases of sudden death aged less than 50 years and is desirable in all sudden death victims
• a substantial proportion of people who die from sudden arrhythmic death syndrome (SADS) and their families are diagnosed with genetic heart disease following clinical and genetic evaluation
• consider competing risk factors for non-arrhythmic death and the patient’s wishes and quality of life when making decisions on the benefits of implantable cardioverter defibrillator therapy
• catheter ablation is recommended for patients who have coronary artery disease with recurrent, symptomatic sustained monomorphic ventricular tachycardia despite chronic amiodarone therapy
• catheter ablation is the first-line treatment for premature ventricular complex-induced cardiomyopathy
• nadolol or propranolol are the preferred beta-blockers in long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) patients.
• routine catheter ablation is not recommended in patients with asymptomatic Brugada syndrome
• exclude underlying structural, channelopathic, or metabolic aetiology when making a diagnosis of idiopathic ventricular fibrillation
• effective refractory period is distinct from early repolarisation syndrome and can be a benign finding
• left cardiac denervation plays an important role in the management of CPVT and LQTS patients.

Quality indicators developed in collaboration with the European Heart Rhythm Association have been aligned with the 2022 ESC guideline.⁶ These consist of 17 main and four secondary quality indicators across eight domains of care:

1. structural framework
2. screening and diagnosis
3. risk stratification
4. patient education and lifestyle modification
5. pharmacological treatment
6. device therapy
7. catheter ablation
8. outcomes.⁶

Avoid Cardiac Complications in Non-cardiac Surgery

The aim of the ESC's guidance on cardiac complications associated with non-cardiac surgery, which was endorsed by the European Society of Anaesthesiology and Intensive Care, is to provide a standardised and evidence-based approach to perioperative cardiovascular management. It recommends a stepwise approach that integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure and the risks involved with discontinuing drugs.³

The key points in the guideline are:

• cardiovascular complications in non-cardiac surgery dramatically impact the prognosis
• the risk of complications is determined by patient-related factors, type of surgery or procedure, and the circumstances under which surgery takes place (such as elective versus emergency procedure; local or tertiary hospital)
• adequate preoperative risk assessment and risk-reduction strategies may reduce patient-related risk factors
• quantify surgical risk into low, intermediate, and high, to identify patients who will benefit most from preventive, diagnostic, and therapeutic approaches to coexisting cardiovascular conditions
• proper selection of the type of surgical procedure and its timing may reduce the risk of complications
• patients’ values, quality of life, and preferences should be taken into consideration, and risk communicated in absolute terms (for example, one in 100)
• clinical examination, patient-reported functional capacity, and non-invasive tests play a key role in preoperative cardiac assessment
• cardiac examination tools should reflect the surgical risk, relative diagnostic proficiency, and impact on healthcare resources and costs
• frailty screening should be used when evaluating elderly patients for major elective non-cardiac surgery
• treatment of pre-existing or newly diagnosed cardiovascular conditions should be individualised
• use a multidisciplinary approach to determine whether to treat cardiac conditions in advance of non-cardiac surgery without creating unnecessary delays
• antithrombotic therapies in the perioperative period should aim to prevent thrombotic events without excessive bleeding
• communicate clearly and concisely with patients any information on changes in medication in the pre- and post-operative phases
• aim to avoid haemodynamic imbalance, while maintaining sufficient cardioprotection, during the perioperative period
• healthcare providers are recommended to have high awareness of perioperative cardiovascular complications, combined with surveillance for perioperative myocardial infarction/injury (PMI) in high-risk patients undergoing intermediate- or high-risk non-cardiac surgery
• routine assessment of the quality of preventive and therapeutic strategies is recommended.³