The European Society of Cardiology (ESC) has released four separate clinical guidelines as part of ESC Congress 2023 addressing the management of acute coronary syndrome (ACS), cardiomyopathies, diabetes and endocarditis. In addition, a focused update of ESC heart failure (HF) guidelines was also published.

The ESC guidelines on ACS cover the management of unstable angina and all types of acute myocardial infarction and provide detailed advice on treatment, including use of anticoagulants and antiplatelet therapy; when to perform radial vs. femoral catheterization; and options for what to do when there is no complete blockage, or when patients are in geographically remote areas. They also address the crucial nature of long-term management to reduce the risk of repeat events, including aggressive control of cholesterol levels, use of medications like antiplatelets, and participation in supervised cardiac rehabilitation programs as a means of encouraging healthy lifestyle changes and increasing activity levels. Additionally, the guidelines include new sections on the management of ACS in patients with cancer, as well as ensuring patient perspectives are used to inform clinical decisions.

The ESC guidelines on cardiomyopathies include all cardiomyopathy subtypes and mark the first time that specific recommendations are made for cardiomyopathies other than hypertrophic cardiomyopathy. They highlight the many areas of diagnosis and management that are shared across cardiomyopathy subtypes and provide specific recommendations, including use of shared decision-making and multidisciplinary teams, for managing each. Of note, the guidelines provide recommendations on the use of imaging techniques, such as echocardiography and cardiac magnetic imaging, for diagnosis of certain cardiomyopathy subtypes and for identifying patients at risk of sudden cardiac death. They also recommend genetic counselling to support patients and their families in understanding the disease and encourage clinical psychological support for all patients who have undergone ICD implantation or who have a family history of sudden cardiac death. A dedicated section of the guidelines also provides specific advice for patients living with cardiomyopathy, including urging low to moderate exercising for those able to do so, healthy diets, vaccination and more.

In the ESC guidelines for the management of cardiovascular disease in patients with diabetes, lifestyle changes, including weight reduction, daily exercise, smoking cessation and diet, are recommended to reduce the likelihood of cardiovascular disease. In addition, recommendations for patients with diabetes and existing cardiovascular disease have been revised following the results of several large clinical trials. For example, the guidelines now recommend SGLT2 inhibitors and/or GLP-1 receptor agonists to reduce the risk of heart attack and stroke in all patients with diabetes and cardiovascular disease, independent of glucose control and concomitant glucose medication, and in addition to standard of care antiplatelet, antihypertensive and lipid-lowering therapies. Managing HF is a special focus of the guidelines, given that patients with diabetes have a two- to four-fold risk of developing HF compared to patients without diabetes. Specifically, the guidelines recommend screening for HF signs and symptoms during each clinical encounter to allow early detection and treatment. Screening for chronic kidney disease is also recommended annually in this patient population. For the first time, the guidelines recommend opportunistic screening for atrial fibrillation by pulse taking or electrocardiogram in patients with diabetes aged 65 years and above. Opportunistic screening is also advised in those below 65 years of age, particularly when other risk factors such as high blood pressure are present. Also new is a recommendation for regular blood pressure measurements in all patients with diabetes to detect and treat hypertension and reduce the risk of cardiovascular disease.

The new ESC guidelines on infective endocarditis recommend that patients with specific cardiac conditions such as valvular heart disease and congenital abnormalities, or those requiring a pacemaker, practice good dental and skin hygiene to help prevent the rare but potentially deadly infections of the heart's inner lining and valves. This means twice daily teeth cleaning, professional dental cleaning (twice yearly for high-risk and yearly for intermediate-risk patients), strict skin hygiene and treatment of chronic skin conditions, and avoiding piercings and tattoos. Recommendations are also provided for diagnosis, treatment, and management of complications, including stroke. The guidelines address when to use echocardiography, computed tomography, nuclear imaging and magnetic resonance imaging plus novel diagnostic algorithms when the infection involves native heart valves, prosthetic heart valves, and implanted cardiac devices such as pacemakers and defibrillators. Additionally, a new section of the guidelines is devoted to patient-centered care and shared decision-making.

For the focused update of the ESC guidelines for HF, the authors took into account results of major new clinical trials like STRONG-HF that are changing how patients are being managed before, during and after discharge. For example, the new document recommends an intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge and during frequent and careful follow-up visits in the first six weeks after hospitalization for HF to reduce readmission and mortality. Additionally, the update stresses the need for clinicians to pay close attention to symptoms and signs of congestion, blood pressure, heart rate, NT-proBNP plasma concentrations, potassium concentrations, and estimated glomerular filtration rate during follow-up, as these factors are linked with prognosis and can signal the need for further changes in treatment. The focused update also provides two new recommendations for the prevention of HF in patients with chronic kidney disease and type 2 diabetes and also provides guidance on the use of intravenous iron supplementation to help address iron deficiency in patients with HF with reduced ejection fraction.

Looking for more resources on these topics? Check out ACC's library of free online education that includes courses on HCM, diabetes, HF and more.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Valvular Heart Disease, Anticoagulation Management and ACS

Keywords: ESC Congress, ESC23, ACC International, Antihypertensive Agents, Blood Glucose, Glucagon-Like Peptide-1 Receptor, Sodium-Glucose Transporter 2 Inhibitors, Anticoagulants, Acute Coronary Syndrome, Diabetes Mellitus, Type 2, Stroke Volume, Electrocardiography, Endocarditis, Cardiomyopathy, Hypertrophic, Angina, Unstable, Heart Valve Diseases, Cardiomyopathies, Pacemaker, Artificial, Renal Insufficiency, Chronic, Magnetic Resonance Spectroscopy, Catheterization

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