New guidelines for cardiac pacing and cardiac resynchronization therapy

ESC publishes new guidelines for cardiac pacing and cardiac resynchronization therapy

August 30, 2007
Michael O'Riordan

Sophia Antipolis, France - On the eve of the European Society of Cardiology (ESC) 2007 Congress, which begins Sunday in Vienna, Austria, the ESC, in partnership with the European Heart Rhythm Association, has released new guidelines for cardiac pacing and cardiac resynchronization therapy (CRT) [1].

The guidelines, now published online in the European Heart Journal, aim to provide an up-to-date specialists' view of the European field and specifically address the issue of permanent pacing in bradyarrhythmias, syncope, and other conditions like hypertrophic obstructive cardiomyopathy and the use of ventricular resynchronization as an adjunct therapy in patients with heart failure.

The new guidelines, by Dr Panos Vardas (Heraklion University Hospital, Greece) and other experts, focus on the use on the appropriate use of pacemakers with various arrhythmias, including sinus node disease, atrioventricular and intraventricular conduction disturbances, pacing disturbances related to AMI, and reflex syncope, among others, and provide recommendations for clinical indications for pacing and the choice of pacing mode.
In addition, the expert panel comments on the rationale for CRT in heart-failure patients, highlights the newest evidence, and makes recommendations according to the different clinical and technical characteristics of the single patient.

"Thanks to important developments in technology and advances in the essential knowledge that we now have concerning the physiology of the paced beat, patients with sinus-node dysfunction and atrioventricular conduction system defects can now be given high-quality therapy," Vardas, chair of the new ESC guidelines, commented in an press release. "These and other developments over the past few years have advanced electrical stimulation further into the realm of ventricular resynchronization as an adjunctive therapy for patients with drug-refractory heart failure and ventricular conduction delay."

The ESC guidelines also highlight the main objectives, structure, and function of a pacemaker clinic and provide recommendations for predischarge assessment of long-term follow-up methodology. The full document, which will soon be published as a pocket-sized version and be available as a personal digital assistant download, is available at the ESC website.

Source:

Vardas PE, Auricchio A, Blanc JJ, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2007; DOI:10.1093/eurheart/ehm305. Available at: http://eurheartj.oxfordjournals.org.

Related links:

Guidelines for cardiac pacing and cardiac resynchronization therapy.
In CRT, ventricular size responds more to biventricular than to LV-only pacing [HeartWire > Heart failure; Apr 13, 2007]
Atrial fib: No reason to avoid resynchronization therapy for heart failure [HeartWire > Heart failure; Mar 20, 2007]
CRT patient-selection criteria: Studies question QRS duration, support tissue-Doppler imaging [HeartWire > Heart failure; Dec 22, 2006]
COMPANION and DEFINITE published: CRT, ICD for HF on threshold of new era [HeartWire > Heart failure; May 19, 2004]

New European guidelines on hypertension

New European guidelines on hypertension

Milan, Italy - New guidelines for the management of arterial hypertension have been issued at the European Society of Hypertension (ESH) meeting in Milan, Italy [1]. The recommendations, which were drawn up jointly by task forces from ESH and the European Society of Cardiology (ESC), also appear in the June 2007 issue of the Journal of Hypertension.

Cochair of the task forces, Dr Guy de Backer (University Hospital, Ghent, Belgium), told heartwire that the guidelines are essentially an update to 2003 recommendations. The new document is 82 pages long and lists 825 references, reflecting the vast amount of data published on the subject of hypertension in the past four years, he noted.

Asked to pick out highlights for heartwire, de Backer said this was a difficult task, "as there has been no one dramatic change, rather small changes in each area. The most important thing is that this is an update and the numerous references have been critically evaluated. We have kept the general framework and added what we think is most important from the literature."

For the clinician, the main messages can be found in a number of boxes in the paper, which contain position statements, he noted. "All you need to do is look at the position statements in the boxes, and read the text only if you want more detail." The task forces are working hard to produce a pocket version of the new guidelines for release at the ESC meeting in Vienna in September, he added.

No one choice of first-line therapy

The overall goal for blood-pressure reduction has remained the same—to lower BP to 140/90 mm Hg in the large majority of people. However, there has been a change in the recommendation for those with comorbidities, de Backer said. For example, there is a new goal of 130/80 mm Hg for people with established cardiovascular disease or diabetes.

In terms of treatment recommendations, he said the new guidelines shy away from recommending one particular class of antihypertensive over another as first-line therapy; rather they emphasize the importance of selecting therapy for each individual, according to any comorbidities they may have.

"We have noted the five important drug classes—diuretics, calcium-channel blockers, ACE inhibitors, beta blockers, and angiotensin-receptor blockers," he said. But from then on, "if we have to make a choice it should depend on comorbidities."

For example, the best choice of first-line agent for someone with hypertension who also has diabetes is either an ACE inhibitor or an angiotensin-receptor blocker. For those who have suffered an MI, the most appropriate drug to use first is a beta blocker, and in the elderly, the first-line drug of choice is generally a calcium-channel blocker to reduce the risk of stroke, he noted.

He added, however, that the emphasis on identification of first-line therapy is often pretty futile, because the majority of patients require multiple blood-pressure medications.


Antihypertensive treatment: Preferred drugs as per new European guidelines

Subclinical organ damage - Treatment


LVH - ACE inhibitors, calcium antagonists, angiotensin receptor blockers

Asymptomatic atherosclerosis - Calcium antagonists, ACE inhibitors

Microalbuminuria - ACE inhibitors, angiotensin receptor blockers

Renal dysfunction - ACE inhibitors, angiotensin receptor blockers


Clinical event


Previous stroke - Any BP-lowering agent

Previous MI - Beta blockers, ACE inhibitors, angiotensin receptor blockers

Angina pectoris - Beta blockers, calcium antagonists

Heart failure - Diuretics, beta blocker, ACE inhibitors, angiotensin receptor blockers, antialdosterone agents

Atrial fibrillation

—Recurrent - Angiotensin receptor blockers, ACE inhibitors

—Permanent - Beta blockers, nonhydropyridine calcium antagonists

ESRD/proteinuria - ACE inhibitors, angiotensin receptor blockers, loop diuretics

PAD - Calcium antagonists


Condition


ISH (elderly) - Diuretics, calcium antagonists

Metabolic syndrome - CE inhibitors, angiotensin receptor blockers, calcium antagonists

Diabetes mellitus - ACE inhibitors, angiotensin receptor blockers

Pregnancy - Calcium antagonists, methyldopa, beta blockers

Blacks - Diuretics, calcium antagonists


LVH=left ventricular hypertrophy; ESRD=end-stage renal disease; PAD=peripheral arterial disease; ISH=isolated systolic hypertension


Other subjects on which there is more information in the new guidelines include the taking of ambulatory BP measurements and those performed at home by patients themselves, de Backer noted, adding that the advice for interpreting ambulatory and home BP measurements "is more detailed now."

Extra information can be found on subclinical organ damage, including details about novel markers for renal damage and arterial stiffness.


Source:
Mancia G, de Backer G, Dominiczak A, et al. 2007 guidelines for the management of arterial hypertension. J Hypertens 2007; 25: 1105-1187


LINK: http://www.theheart.org/article/797619.do#

ESC - Summary reports and slides are available online during the Heart Failure 2007 Congress in Hamburg from 9 to 12 June 2007.

Scientific Reports

Heart Failure 2007 Congress

The following presentations were selected by the Scientific Committee of the Heart Failure Association of the ESC as of particular interest.

Please click on title to see session details.

Summary reports and slides are available online during the Heart Failure 2007 Congress in Hamburg from 9 to 12 June 2007.------------------------------------------------------------------------------------------------

Future of Biomarkers in Heart Failure Prof Eugène BraunwaldEugene Braunwald, M.D. is the Distinguished Hersey Professor of Medicine at Harvard Medical School, and Chairman of the TIMI Study Group at the Brigham and Women’s Hospital.Slides (PDF 1,7 Mb)
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BNP is is an obligatory biomarker for longterm management of chronic heart failure - ProProf. Guillaume JondeauSummary: Despite advances in medical therapy of heart failure, mortality remains high. A new approach would be to improve monitoring of patients with chronic heart failure. Biomarkers such as BNP clearly rises this possibility and indications are coming from tials that use of this new parameter is associated with decreased hospitalisation rate.Report Slides

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Levosimendan is a firstline drug in the management of acute heart failure - ProProf. Ferenc FollathSummary: The efficacy of levosimendan, a novel drug with positive inotropic and vasodilating actions, was well documented in patients with decomepensated chronic heart failure with high filling pressures and low cardiac output. Proper pretreatment evaluation is essential to select suitable patients for application as a firstline treatment and to avoid problems due to excessive vasodilation.Slides
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Levosimendan is a firstline drug in the management of acute heart failure - ContraProf. John ClelandSummary: Levosimendan proved superior to dobutamine in terms of haemodynamics and survival when studied in patients with severe chronic heart failure in the LIDO study. However, two large studies of levosimendan in acute heart failure failed to show convincing evidence of benefit overall on morbidity or mortality. A modest improvement in symptoms was observed compared to placebo in one study which requires confirmation. Important benefits might have occurred in some subgroups of patients but this also requires confirmation.Slides
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Detection and treatment of depression in routine care of patients with heart failureProf. Christiane E AngermannSummary: On systematic screeening, depression is frequently diagnosed amongst patients with chronic heart failure, and is known to carry an adverse prognosis. Up to now, no efficacy data regarding hard clinical endpoints are available for any treatment modality of depression in this patient population; however, selective serotonin re-uptake inhibition may favourably influence the mortality risk by improving health behaviour and/or via direct modulation of biological pathways.Report Slides
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Haemodynamic monitoring: tool or toy? Assoc.Prof. Gerasimos FilippatosSummary: Hemodynamic variables have been considered necessary to guide treatment in critically ill heart failure patients but recent trials did not show any benefit from pulmonary artery catheter (PAC) use. However, the detrimental outcomes may not emanate from the use of a PAC per se but from the lack of effective therapies, lack of knowledge about appropriate use of information received from the PAC or because the information is obtained very late in the course of the disease. New devices could provide additional insight into the difficult problem of early evaluation and management of patients with heart failure.Slides
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The adult human atrium a realistic cell source for therapy?Prof. Pieter DoevendansSummary: The human atrial auricle contains cardiomyocyte progenitor cells. These cells are present in small groups and can be grown as stem cells in a high volume and differentiated very efficiently into human cardiomyocytes. Potentially these cells can be used for cell transplantation and tissue engineering.