ESC 2023 Guidelines Reflect Treatment Advances and New Trial Findings

Guidelines in Practice Assesses New and Updated Guidance Published in 2023 by the European Society of Cardiology at its Annual Congress

Introduction

Each year, the European Society of Cardiology (ESC) unveils a raft of new and updated guidance at its annual conference, alongside the findings from hotline sessions and late breaking trials. The 2023 ESC Congress (Amsterdam, 25–28 August) was no exception, with the publication of four clinical guidelines and a focused update of heart failure guidance.¹

Full guidelines presented at the Congress covered the management of cardiomyopathies,² acute coronary syndromes (ACS),³ cardiovascular disease in patients with diabetes,⁴ and endocarditis.⁵ Guidelines in Practice examines the new guidance and the focused update, and provides an analysis of each.

A Wider Approach to Cardiomyopathies

The new ESC guideline on cardiomyopathies replaces 2014 guidance on hypertrophic cardiomyopathy (HCM)⁶ to take into account advances in genetics and cardiac imaging.² It features recommendations on various subtypes of cardiomyopathy, focusing on the most common disease phenotypes, and contains information on less common disorders.²  

The new guidance provides a guide to diagnostic approaches, highlights evaluation and management issues, and signposts to the evidence base for recommendations.²

The guidance covers paediatric, adolescent, and adult cardiomyopathies, and the different clinical phases (for example, concealed, overt, end stage), with recommendations on sudden cardiac death (SCD) risk stratification. It also provides lifestyle advice for patients with cardiomyopathy.² A multidisciplinary approach is encouraged, as is an integrated patient management strategy that includes the patient’s family and clinical findings in relatives, which the guidance describes as ‘essential for understanding what happens to the patient’.² 

Some Key Recommendations on Cardiomyopathies

• Determine aetiology, as this is essential for diagnosis and management 
• Characterise cardiac phenotype using multimodality imaging
• Take a detailed personal and family history, and conduct a clinical examination, electrocardiography, and laboratory investigations
• Interpret imaging results in the overall clinical context, including genetic testing results
• Ensure appropriate transition of care from paediatric to adult cardiomyopathy services 
• Infant-onset cardiomyopathy (in the first year of life) is often associated with severe phenotypes and a high rate of heart failure-related morbidity and mortality 
• Genetic causes of childhood-onset cardiomyopathy (beyond the first year of life) are similar to those in adults
• Symptom management, identification, and prevention of disease-related complications (such as SCD, heart failure, and stroke) are the cornerstone of management of all cardiomyopathies
• Validated risk-prediction tools such as HCM Risk-SCD and HCM Risk-Kids are the first step in sudden death prevention for patients with HCM.²

A Combined Guideline for Acute Coronary Syndromes

The ESC has merged its guidance on ACS, previously considered in two separate guidelines,^7,8 and a single guideline now encompasses a spectrum that includes ST-elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE–ACS).³ Because of similarities in management, the guidelines committee recommends both be considered under a similar pathway once the acute management and stabilisation phase has passed.³

The guideline features new recommendations on the use of antiplatelet and anticoagulation therapy, treating multivessel disease, managing ACS complications, and the intensification of lipid-lowering therapy. New recommendations are also provided for the management of comorbid conditions, including for patients with ACS who have cancer. The guidance advocates a medically supervised, structured, comprehensive, multidisciplinary exercise-based cardiac rehabilitation and prevention programme, and the adoption of a healthy lifestyle for all patients with ACS.³

Other Key Recommendations for Acute Coronary Syndromes

• For patients with suspected NSTE–ACS, use high-sensitivity troponin measurements and rapid ‘rule-in’ and ‘rule-out’ algorithms 
• Emergency services should take STEMI patients straight to 24/7 high-volume percutaneous coronary intervention (PCI) centres, regardless of the initial treatment strategy (primary PCI or pre-hospital fibrinolysis)
• Invasive strategies are recommended; these are time sensitive:
  • for STEMI and very high-risk NSTE–ACS, use an immediate invasive strategy 
  • for patients with NSTE–ACS, use an inpatient invasive strategy 
  • for NSTE–ACS patients with high-risk characteristics, consider an early invasive strategy (within 24 hours) 
• All ACS patients should receive antithrombotic therapy, regardless of management strategy. This can be both antiplatelet and anticoagulant therapy:
  • aspirin is recommended at an initial loading dose of 150–300 mg, and a long-term maintenance dose of 75–100 mg daily for all ACS patients 
  • in addition, a P2Y₁₂ inhibitor is recommended for at least one year, unless there is a high bleeding risk
  • consider prasugrel and ticagrelor in preference to clopidogrel
  • consider prasugrel in preference to ticagrelor for ACS patients undergoing PCI
  • P2Y₁₂ inhibitor therapy before coronary angiography in patients with NSTE–ACS is not recommended routinely, but can be considered for patients with STEMI undergoing primary PCI
• Admit high-risk ACS patients, including all STEMI patients, to a coronary care unit or intensive cardiac care unit following reperfusion
• Electrocardiogram monitoring for arrhythmias and ST-segment changes should continue for at least 24 hours after symptom onset in all high-risk patients with ACS
• Routine radial access and drug-eluting stents can be considered the standard of care during PCI for ACS
• Routine thrombus aspiration is not recommended during primary PCI
• Base the revascularisation strategy for patients who have multivessel disease on clinical status, comorbidities and disease complexity, according to the principles of management of myocardial revascularisation
• Use an invasive strategy for patients with cancer presenting with high-risk ACS whose expected survival is >6 months, but consider a non-invasive strategy for those with a poor cancer prognosis (expected survival <6 months) or a very high bleeding risk.³

A Focus on Heart Failure Management

In recognition of more than 10 randomised controlled trials whose findings should be incorporated into heart failure management before the next full update of the guideline is due, the ESC has published a focused update of its 2021 guideline.^1,9 This provides new recommendations on acute heart failure, chronic heart failure, and comorbidities, including:¹

• Chronic heart failure: the ESC recommends the use of dapagliflozin or empagliflozin for patients with symptomatic heart failure with mildly reduced ejection fraction or symptomatic heart failure with preserved ejection fraction to reduce the risk of hospitalisation,¹ based on findings from the EMPEROR-Preserved¹⁰ and DELIVER¹¹ trials
• Acute heart failure: the ESC recommends high intensity care for the initiation and rapid up-titration of oral heart failure therapies before discharging patients hospitalised with acute heart failure, as well as close follow up after discharge,¹ as shown in the STRONG-HF trial¹² 
• Comorbidities: the DAPA-CKD¹³ and EMPA-KIDNEY¹⁴ trials informed a new recommendation for the use of dapagliflozin or empagliflozin to reduce the risk of hospitalisation or cardiovascular death in patients with chronic kidney disease (CKD) and type 2 diabetes.¹ The mineralocorticoid receptor antagonist, finerenone, can also be used in patients with these comorbidities to reduce the risk of hospitalisation,¹ as demonstrated by the FIDELIO-DKD¹⁵ and FIGARO-DKD trials.¹⁶

Updated Guidance on Cardiovascular Disease in Patients with Diabetes

A guideline on the management of cardiovascular disease (CVD) in patients with diabetes⁴ updates ESC guidance published in 2019.¹⁷ The 2023 guidance focuses solely on CVD and diabetes and has no recommendations for pre-diabetes, due to a lack of clear evidence.⁴

Key Revisions and Changes 

• A modification to the assessment of CV risk in patients with diabetes, with a recommendation that all patients who have diabetes be checked for the presence of CVD and severe target-organ damage (defined based on estimated glomerular filtration rate [eGFR], urinary albumin-to-creatinine ratio, or microvascular disease present in at least three different sites [such as microalbuminuria plus retinopathy plus neuropathy]) 
• A novel type 2 diabetes-specific 10-year CVD risk score (the SCORE2-Diabetes algorithm) to classify patients with type 2 diabetes without atherosclerotic CVD or severe target-organ damage as low, moderate, high, or very high CV risk. This combines information on conventional CVD risk factors (age, smoking status, systolic blood pressure, and cholesterol levels) with diabetes-specific information (age at diabetes diagnosis, glycated haemoglobin, and eGFR)
• A recommendation for systematic screening for diabetes in all patients with CVD
• A recommendation that patients with diabetes and atherosclerotic CVD be treated with glucagon-like peptide-1 receptor agonists and/or sodium–glucose co-transporter-2 (SGLT-2) inhibitors to reduce CV risk, independent of glucose control and in addition to standard antiplatelet, antihypertensive, and lipid-lowering therapies
• A recommendation to treat all patients with diabetes and chronic heart failure with an SGLT-2 inhibitor to reduce the risk of heart failure hospitalisation and CV death, regardless of left ventricular ejection fraction 
• A recommendation to screen all patients with diabetes for risk and presence of CKD and, if detected, to treat with an SGLT-2 inhibitor and/or finerenone to reduce the risk of CV events and kidney failure
• A focus on early identification and treatment of other risk factors and comorbidities.⁴

New Recommendations for Infective Endocarditis

The ESC has also updated guidance last published in 2015 on infective endocarditis.¹⁸ The new guideline takes account of advances in transcatheter valve interventions, and features new recommendations on prevention, diagnosis, and management.⁵ Risk categories have been revised, recommendations for antibiotic prophylaxis strengthened, and the definition of the population at risk has been clarified. There are also new recommendations covering the role of computed tomography, magnetic resonance imaging, and nuclear imaging in diagnosis, with the provision of algorithms for the diagnosis of native valve infective endocarditis, prosthetic valve infective endocarditis, and cardiac device-related infective endocarditis. 

Indications and timing of surgery for the prevention of an embolism in both native and prosthetic valve infective endocarditis have also been revised. Urgent surgery (within 3–5 days) is recommended for cases of infective endocarditis in which vegetation is ≥10 mm, and surgery is also recommended for patients with early prosthetic valve endocarditis. In other complications, mechanical thrombectomy can be considered in some cases of embolic stroke, if it can be provided in a timely manner and the expertise is available.⁵