The key issues of the 2022 ESC Guidelines

The ESC published four new guidelines in 2022. We present the most important take-aways, as presented in the German Cardiology Congress (DGK) 2023.

First guidelines on cardio-oncology

The first ESC guideline on cardio-oncology includes 272 new recommendations and emphasises the importance of integrating cardiology, oncology and haematology to provide the best possible care for cancer patients with cardiovascular disease (CVD). Communication between different disciplines is of great importance.

Cardio-oncology programs should be set up in large medical centres. These can optimise cancer treatment by minimising unnecessary interruptions and taking into account possible CVD during cancer treatment. Early risk assessment for CVD is recommended for all patients to optimise cancer treatment choices and personalise screening and monitoring for cardiovascular problems.

Of importance in this context is both primary prevention and secondary prevention in patients with pre-existing CVD. Structured monitoring during cancer therapy with echocardiography, left ventricular strain analysis and biomarkers (NT-ProBNP, troponin and creatine) is recommended to detect possible cardiac damage and treat it accordingly.

After completion of a cancer treatment, long-term monitoring of patients at increased risk for CVD must be ensured. Involving patients and relatives in the treatment process and providing psychological support are also important factors for successful cardio-oncology.

Guidelines on cardiac management before non-cardiac surgery

In the European Union, at least 660,000 major cardiovascular complications occur each year due to non-cardiac surgery. The ESC guidelines on this are primarily dedicated to the prevention of such events.

The likelihood of cardiovascular complications depends on several factors, including the type of surgery. Surgeries are categorised as low (less than 1%), medium (1-5%) and high (over 5%) depending on the surgical risk. This is the likelihood of a heart attack, stroke or death due to cardiovascular disease within 30 days.

In patients aged 45-65 years without signs or symptoms of cardiovascular disease, electrocardiograms and troponin measurements should be performed before and after high risk non-cardiac surgery.

The guidelines also include individualised recommendations for patients with various cardiovascular diseases, renal disease, diabetes, cancer, obesity, and COVID-19. Patients with existing heart disease are at higher risk for perioperative cardiovascular complications, especially older patients. All patients with coronary artery disease should undergo cardiac evaluation.

The decision to perform invasive diagnostic procedures such as coronary angiography should be made on an individual basis, based on symptoms and the presence of pre-existing conditions. After COVID-19, elective non-cardiac procedures should be postponed until full recovery and optimisation of comorbidities.

Ventricular tachycardia and sudden cardiac death prevention

After seven years, the European Society of Cardiology (ESC) has updated the guidelines for the treatment of patients with ventricular arrhythmias and the prevention of sudden cardiac death. In doing so, it emphasises the importance of basic CPR training.

The guidelines call for more automated external defibrillators (AEDs) in public places such as shopping malls, stadiums and train stations, as well as broader public training in the use of CPR and AEDs to increase chances of survival from sudden cardiac death. Only about 10% of the six million people worldwide who suffer sudden cardiac death each year survive. The guideline authors also emphasise the need for healthy lifestyles to prevent coronary heart disease, which is responsible for 75-80% of sudden cardiac deaths in the Western world.

The guidelines also recommend an evaluation of sudden cardiac death victims and their families, to identify inherited cardiac conditions that may be of relevance. They also emphasise the importance of a comprehensive autopsy to determine the probable cause and potential presence of genetic disease.

A cardiovascular screening is recommended for athletes to identify undetected conditions that could cause sudden cardiac death. The guidelines also recommend that staff at sports venues should be trained in the use of CPR and AEDs to increase chances of survival in the event of sudden cardiac death.

Guidelines for the treatment of pulmonary hypertension

The ESC and the European Respiratory Society (ERS) have published a new guideline on the diagnosis and management of pulmonary hypertension. The guidelines emphasise the importance of early diagnosis and expedited referral of patients with high risk or complex cases.

Pulmonary hypertension is a serious disease that can lead to increased mortality if not successfully treated. The disease affects about 1% of the global population and up to 10% of people over the age of 65. Symptoms include progressive breathlessness on effort and reduced exercise tolerance. Climbing can be difficult and many patients experience chronic fatigue. The guidelines also recommend psychosocial support for patients with pulmonary arterial hypertension, as many develop depression and anxiety and have to reduce their work.

The guidelines cover the full spectrum of pulmonary hypertension, with a focus on the diagnosis and treatment of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Early diagnosis and treatment are critical for pulmonary arterial hypertension, and most patients should receive a combination of at least two medications.

Women with pulmonary arterial hypertension should be cautioned against pregnancy, as it may be associated with significant risks to both mother and child. Open pulmonary endarterectomy (PEA) is the preferred treatment strategy for chronic thromboembolic pulmonary hypertension. Minimally invasive balloon pulmonary angioplasty is increasingly performed in specialised centres and is considered a good alternative. Multidisciplinary teams are central to the diagnosis and treatment of pulmonary hypertension.


DGK Session: To the point - The most important aspects of the 2022 ESC Guidelines in one session. (Original German Session: Auf den Punkt gebracht – Das Wichtigste der 2022 ESC Leitlinien in einer Sitzung; DGK 2023, 15.4.2023 8.30 Uhr)