2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

Five updated Guidelines were presented during this year’s ESC congress. Those on dyslipidemia and diabetes, pre-diabetes and CVD have been described elsewhere on this site. Here we briefly touch on some of the new ESC recommendations on acute pulmonary embolism, supraventricular tachycardia and chronic coronary syndromes, based on the Congress Condensed session on Guidelines held on Wednesday September 4.

Click here to find the guidelines on acute pulmonary embolism (PE).

These guidelines are an update to the version published in 2014. Many recommendations have been retained or their validity has been reinforced; however, new data have extended or modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE. These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or confirmed PE.

During the congress condensed session, professor Nazzareno Galiè (Bologna, Italy) presented the new diagnostic algorithms for suspected PE, which differ for those at high risk and those at low risk, without hemodynamic instability. New recommendations for PE diagnosis include consideration of an age-adjusted cut-off for the D-dimer test, or an adaptation to clinical probability, instead of the fixed cut-off level.

Regarding risk assessment, a clear definition of hemodynamic instability and high-risk PE is now provided. It is stressed that right ventricle dysfunction may be present and affect early outcomes in patients considered at low risk based on clinical risk scores. Validated scores that combine clinical, imaging and laboratory prognostic factors may be considered to further stratify PE severity.

New recommendations also concern treatment in the acute phase. The section on hemodynamic and respiratory support is thoroughly revised and a risk-adjusted management algorithm is proposed, with separate pathways for those at low, intermediate and high risk. NOACs are the preferred form of anticoagulation. Recommendations for chronic treatment to prevent VTE recurrence are also given, taking into account the level of risk for recurrence, and the bleeding risk on anticoagulation.

Special recommendations are given on how to manage PE in cancer or during pregnancy. Moreover, a comprehensive algorithm is proposed for patient follow-up after acute PE and management of long-term sequelae, including optimal transition from hospital to community care.

2019 Guidelines on supraventricular tachycardia

Click here to find the guidelines on supraventricular tachycardia (SVT).

The last guidelines on SVT were published in 2003. Professor Christian Sticherling (Basel, Switzerland) noted that at the time, ablation was still in its infancy, while it is currently our main tool. The current guidelines address all SVT, but not atrial fibrillation. Few randomized controlled trials have been performed in this field, thus many recommendations reflect current practice and expert opinions.

He zoomed in on some of the new recommendations, and showed that there are many helpful flowcharts to facilitate decisions in the clinical setting. Sticherling stressed that catheter ablation has come to the foreground for treatment of SVT, while several medication options have been dropped.

The guidelines include various new chapters on clinically relevant aspects in different populations with PSVT, including SVT in adults with congenital heart disease, SVT during pregnancy, tachycardia-induced cardiomyopathy, SVT in sports and SVT and driving restrictions.

He ended his brief presentation with evidence-based ‘what do do’ and ‘what not to do’ messages on acute and chronic management of various forms of SVT (also summarized in the guidelines).

2019 Guidelines on chronic coronary syndromes

Click here 9https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Chronic-Coronary-Syndromes) to find the guidelines on chronic coronary syndromes.

The most prominent change in these guidelines since their last version published in 2013 is the focus on the chronic but progressive nature of the pathological process underlying coronary artery disease (CAD), instead of stable CAD.

Franz-Josef Neumann (Bad Krozingen, Germany) showed a graph that depicts the natural history of chronic coronary syndromes (CCS): steadily increasing cardiac risk with time, interrupted by acute exacerbations. This disease process can be modified by lifestyle, medications or revascularization. It is the ultimate goal of the guidelines to guide risk-modifying management of patients with CCS.

The current Guidelines on CCS identify six clinical scenarios most frequently encountered in patients, for which detailed diagnostic pathways are given:

• patients with suspected CAD and ‘stable’ anginal symptoms, and/or dyspnoea;
• patients with new onset of HF or LV dysfunction and suspected CAD;
• asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS or patients with recent revascularization;
• asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization;
• patients with angina and suspected vasospastic or microvascular disease;
• asymptomatic subjects in whom CAD is detected at screening.

The Guidelines have revised the ‘pre-test probability’ (PTP) of CAD in those with angina and/or dyspnea and suspected CAD, specified for age categories and sex and nature of symptoms. The concept of ‘clinical likelihood of CAD’ is newly introduced, which refers to risk factors of CAD that modify the PTP.

The role of exercise ECG has been downgraded in the guidelines; a class I recommendation is only given for its use in risk assessment. Some changes have been made to recommendations on anti-ischemic medication. Also, recommendations on event prevention have been updated to use of dual antithrombotic therapy and specific guidance is given on which agent may be added to aspirin in specific clinical scenarios. Recommendations also include use of other drugs for event prevention, including lipid-lowering drugs (statins, ezetimibe, PCSK9 inhibitors) and antidiabetic drugs (SGLT2 inhibitors, GLP-1 receptor agonists).

The guidelines include a decision tree for patients undergoing invasive coronary angiography, with advice on what to do next in presence or absence of angina symptoms, documented ischemia and multivessel disease.

Find all ESC Guidelines here