BARCELONA – Routine use of a new risk calculator tool to estimate the 5-year risk of sudden cardiac death is recommended in all patients with hypertrophic cardiomyopathy in updated guidelines launched at the annual congress of the European Society of Cardiology.
Bruce Jancin/Frontline Medical News
Dr. Perry M. Elliott
“Based on that estimate, you can now have an intelligent conversation with the patient about what the threshold is for implantable cardioverter-defibrillator placement given an individual’s risk/benefit ratio,” explained Dr. Perry M. Elliott, chair of the guidelines task force and professor of inherited cardiovascular disease at The Heart Hospital, London.
The hypertrophic cardiomyopathy guidelines were among five new practice guidelines introduced at the annual congress. Others addressed acute pulmonary embolism, noncardiac surgery, myocardial revascularization, and aortic diseases.
Here are selected highlights of the new guidelines:
• Hypertrophic cardiomyopathy. The novel sudden cardiac death risk prognostication tool, known as HCM Risk-SCD, is a major innovation in the new guidelines. The risk calculator grew out of a recent multicenter study of nearly 3,700 patients conducted by Dr. Elliott and his coinvestigators (Eur. Heart J. 2014;35:2010-20).
Now physicians can plug a series of validated risk factors into an online calculator and receive an estimated 5-year risk figure. The input factors include maximal wall thickness, left atrial diameter, family history of sudden cardiac death, unexplained syncope, and maximal left ventricular outflow gradient. If the estimated 5-year risk is 6% or more and the patient has a life expectancy of more than a year, implantation of a cardioverter-defibrillator should be seriously considered, according to the guidelines.
Bruce Jancin/Frontline Medical News
Dr. Juhani Knuuti
“What we’re trying to do in these guidelines is to change a mind-set, because hypertrophic cardiomyopathy is not really a diagnosis; it actually represents a family of diseases. Running throughout this entire document is an emphasis on individualization, from diagnosis all the way through treatment,” Dr. Elliott said. “There’s a strong emphasis on making a specific diagnosis if you possibly can, because these subtypes of cardiomyopathy have totally different natural histories and in the future will have very different treatments.”
Other highlights of the new guidelines include a stepwise approach to management of left ventricular outflow tract obstruction and heart failure, advice on reproduction, suggestions regarding simple laboratory tests with diagnostic utility, and guidance on the effective utilization of ECG, echocardiography, and cardiac magnetic resonance imaging.
“We show a number of echocardiographic red flags, some of which are perhaps not readily appreciated in everyday practice,” Dr. Elliott said. “For example, the presence of hypertrophy with impaired systolic function immediately narrows down your diagnosis to one of five or six different conditions.”
• Pulmonary embolism. The new guidelines place the novel oral anticoagulants rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa), and edoxaban (Savaysa) on equal footing with once-standard warfarin.
Task force chair Dr. Stavros Konstantinides highlighted as new in the 2014 guidelines a strong recommendation that patients who do not have a high-risk pulmonary embolism – that is, those who are not in shock or hypotensive – should be scored using the Pulmonary Embolism Severity Index or another validated clinical risk prediction score. The purpose is to distinguish between those at low versus intermediate risk.
Those at intermediate risk should undergo right ventricular imaging via CT or echocardiography, along with a biomarker test for myocardial injury. If both the imaging study and biomarker are positive, the patient is classified as being at intermediate-high risk; if not, intermediate-low. This has treatment implications, since it’s recommended that systemic thrombolysis be considered only in those with intermediate-high-risk pulmonary embolism and clinical signs of hemodynamic decompensation, explained Dr. Konstantinides of University Medical Center in Mainz (Germany).
• Noncardiac surgery. Perioperative initiation of beta-blocker therapy is no longer recommended routinely, but may be considered in patients scheduled for high-risk noncardiac surgery who also have two or more cardiovascular risk factors or known ischemic heart disease. Atenolol and bisoprolol are recommended as the perioperative beta-blockers of choice. If a patient is already on a beta-blocker prior to surgery, the drug can be continued perioperatively, according to task force cochair Dr. Juhani Knuuti of the University of Turku (Finland).
The guidelines emphasize that prophylactic coronary revascularization is seldom indicated in patients undergoing noncardiac surgery that has a low or intermediate cardiovascular risk.
• Myocardial revascularization. These guidelines, with more than 300 recommendations, are the lengthiest of the five new sets of guidelines. The myocardial revascularization guidelines rely heavily upon the findings of a recent meta-analysis conducted by task force cochairs Dr. Stephan Windecker of Bern (Switzerland) University and Dr. Philippe Kohl of the University of Liege (Belgium) and their coinvestigators. The meta-analysis encompassed 100 randomized controlled trials with nearly 94,000 randomized patients and more than 262,000 patient-years of follow-u p (BMJ 2014 June 23 [doi: 10.1136.bmj.g3859]).