New ESC Guidelines 2023: An overview

The guidelines publication is one of the most eagerly awaited moments of the annual congress organised by the European Society of Cardiology. The 2023 edition, which took place in Amsterdam on 25-28 August, saw the presentation of five new guidelines:

Acute coronary syndromes

Acute coronary syndromes include conditions such as unstable angina and myocardial infarction. The new ESC guidelines provide detailed treatment recommendations, including drug therapy and interventions such as coronary angioplasty. The guidelines emphasise the importance of timing in the treatment of acute coronary syndromes, pointing out that early intervention is crucial to prevent heart damage.

The document emphasises that acute coronary syndromes affect not only men but also women, urging the need to provide effective evidence-based care for both sexes. After an episode of acute coronary syndrome, it is crucial to care for patients in the long term, both by managing drug therapy and through rehabilitation programmes and the promotion of a healthy lifestyle.

The guidelines also address the management of acute coronary syndromes in cancer patients, since such patients have a high risk due to factors such as smoking, the cancer diagnosis itself, and ongoing chemotherapy/radiotherapy treatment. Finally, the guidelines recommend considering the views of patients, involving them in the decision-making process and adequately informing them about the risks and alternatives available.

Heart failure

The new ESC heart failure guidelines (a "focused update" of the 2021 guidelines) include newly developed evidence-based therapies, meta-analyses, and randomised trials to improve the management and outcome of patients with heart failure.

The new recommendations focus on three main areas: chronic heart failure, acute heart failure, and comorbidities. Among the main recommendations is the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors. Use is recommended in patients with reduced or preserved heart ejection fraction (HFmrEF and HFpEF) to reduce the risk of hospitalisation for heart failure or cardiac arrest. Use is also recommended in patients with chronic renal disease and type 2 diabetes to reduce the risk of heart failure. The use of finerenone is also recommended in these patients to reduce the risk of hospitalisation for heart failure.

Finally, the new ESC guidelines emphasise the importance of iron supplementation for heart failure patients with reduced or moderately reduced ejection fraction to improve symptoms and quality of life and to reduce the risk of hospitalisation for heart failure.

Cardiomyopathies

The European Society of Cardiology guidelines on cardiomyopathies are the first international document to include all subtypes of cardiomyopathy and, for the first time, specific recommendations are given for cardiomyopathies other than hypertrophic cardiomyopathy. For the first time, cardiomyopathies are considered in a unified manner.

These guidelines reflect advances in genetics and cardiac imaging and the introduction of new treatments targeted at specific causes of the disease. They focus on patients and their families, from the moment a person presents with symptoms or is diagnosed incidentally/family history, through to the precise framing and initiation of treatment.

The guidelines emphasise the different stages of diagnosis and management shared between the subtypes of cardiomyopathy and provide specific recommendations for each. Diagnosis begins with the evaluation of cardiac structure and function through examinations such as echocardiography and cardiac MRI. In addition, family history and genetic tests are considered to arrive at a more precise diagnosis.

The management of cardiomyopathies aims to identify and treat symptoms, prevent complications and screen family members at risk. The guidelines provide recommendations for genetic counselling, psychological support and the use of devices such as implantable cardioverter-defibrillators (ICDs) to prevent sudden death. In addition, lifestyle and condition issues are addressed, such as exercise, diet, alcohol, pregnancy, and more.

The guidelines also promote the importance of low- to moderate-intensity exercise for patients with cardiomyopathy, as this can help improve their condition. However, an individual risk assessment is recommended to establish an appropriate exercise plan. Finally, the importance of a multidisciplinary approach in the care of patients with cardiomyopathy and the need for an appropriate transition from paediatric to adult care is emphasised.

Cardiovascular diseases and diabetes

The new European Society of Cardiology (ESC) guidelines for the management of cardiovascular disease in patients with diabetes were created to address the fact that patients with type 2 diabetes have a more than two times higher risk of developing cardiovascular disease than those without diabetes.

The guidelines emphasise the importance of cardiovascular disease prevention and management in patients with diabetes. They recommend systematic screening for diabetes in all patients with cardiovascular disease and vice versa, to assess the risk and presence of cardiovascular disease in all patients with diabetes. They introduce a new score called SCORE2-Diabetes to estimate the 10-year risk of myocardial infarction and stroke in patients with type 2 diabetes, based on traditional and diabetes-specific risk factors.

The guidelines recommend lifestyle changes for all patients with diabetes to reduce cardiovascular risk, including weight loss and regular exercise. They also recommend quitting smoking and following a Mediterranean or vegetable-based diet rich in unsaturated fats.

For patients with coexisting diabetes and cardiovascular disease, the recommendations have been revised following the results of large clinical trials. The guidelines now recommend the use of SGLT2 inhibitors and/or GLP-1 receptor agonists to reduce the risk of myocardial infarction and stroke in all patients with diabetes and cardiovascular disease, regardless of glycaemic control and glycaemic therapy.

The guidelines also provide specific recommendations for the management of heart failure in patients with diabetes, emphasising the importance of screening for signs and symptoms of this condition. They recommend the use of SGLT2 inhibitors to reduce the risk of hospitalisation for heart failure in patients with diabetes and chronic heart failure.

In addition, guidelines recommend opportunistic screening for atrial fibrillation in patients > 65 years with diabetes and also in younger patients, especially when other risk factors such as hypertension are present. It is also recommended that blood pressure be measured regularly in all patients with diabetes to detect and treat hypertension and reduce cardiovascular risk.

The guidelines recognise that diabetes is a greater risk factor for cardiovascular disease in women than in men. They recommend greater representation of women in clinical trials and an effort to ensure that women receive equal health care opportunities in the management of cardiovascular disease and diabetes.

Endocarditis

The new ESC 2023 guidelines on infective endocarditis emphasise the importance of prevention and early recognition of this condition in specific patients, such as those with valvular heart disease and congenital heart abnormalities, or those in need of a pacemaker.

Persons at higher risk include those who have had previous episodes of infective endocarditis, patients with prosthetic heart valves, congenital heart disease or left ventricular assist devices. In these patients, antibiotic prophylaxis prior to oral or dental procedures is recommended. In other patients, such as those with pacemakers, severe valvular heart disease, congenital heart valve abnormalities and hypertrophic cardiomyopathy, antibiotic prophylaxis should be individually assessed. Antibiotic prophylaxis is not necessary for low-risk subjects.

The guidelines also recommend preventive measures such as good oral and skin hygiene - brushing teeth twice a day, professional dental cleanings and treatment of chronic skin conditions. Piercings and tattoos are not recommended.

The recommendations also cover diagnosis, treatment and management of complications. Diagnosis is based on clinical suspicion, blood cultures and imaging. Echocardiography is the first-line imaging technique, but there are new recommendations on the use of computed tomography, nuclear imaging and magnetic resonance imaging.

Treatment aims to cure the infection and preserve the function of the heart valve. Guidelines recommend appropriate antibiotics as the main therapy, with duration depending on the severity of the infection. Surgery is indicated for patients with heart failure or uncontrolled infection. A further recommendation is to proceed with heart valve surgery in case of ischaemic stroke caused by embolism, but to delay surgery in case of haemorrhagic stroke.

The new guidelines devote a section to patient-centred care and shared decision-making. It is recognised that infective endocarditis is a potentially devastating condition both physically and emotionally, and the importance of involving patients in the management of their health is emphasised.

Press release. First ESC Guidelines covering all acute coronary syndromes published today. ESC Press Office. 25 Aug 2023.
Press release. Focused update of ESC Heart Failure Guidelines published today. ESC Press Office. 25 Aug 2023.
Press release. First international guidelines on heart muscle diseases published today. ESC Press Office. 25 Aug 2023.
Press release. Recommendations to reduce cardiovascular risk in patients with diabetes published today. 25 Aug 2023.
Press release. Patients urged to be vigilant about cardiac infections. ESC Press Office. 25 Aug 2023.