MD Conference Express ESC 2012 - (Page 8)
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antagonist (VKA), direct thrombin inhibitor, or factor Xa inhibitor. If patients refuse any OAC, antiplatelet therapy should be considered. A NOAC is recommended when an adjusted-dose VKA cannot be used. The oral antiarrhythmic dronedarone is recommended for patients with recurrent AF but not in patients with permanent AF due to an increase in mortality in the latter group. LAA closure may be considered in patients with high stroke risk and contraindications for long-term OAC. When pharmacologic cardioversion is preferred and there is no or minimal structural heart disease, IV flecainide, propafenone, ibutilide, or vernakalant are recommended. Catheter ablation is recommended in patients who have symptomatic recurrences of AF on antiarrhythmic drug therapy and who prefer further rhythm control therapy. Valvular Heart Disease The 2012 ESC/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines on the management of valvular heart disease were developed because of new evidence on risk stratification, diagnostic methods, and therapeutic options [Vahanian A et al. Eur Heart J 2012; Eur J Cardio Thorac Surg 2012]. Alec Vahanian, MD, Hôpital Bichat, Paris, France, and Ottavio Alfieri, MD, Università VitaSalute San Raffaele, Brescia, Italy, presented an overview of these updates. The guidelines address the following key areas: patient evaluation, aortic regurgitation (AR), aortic stenosis (AS), mitral regurgitation (MR), tricuspid disease, and valve prostheses. Patients should be evaluated for symptoms, severity of valvular disease, life expectancy, quality of life, and benefits versus risks of intervention. In the absence of a perfect quantitative score, risk assessment should primarily rely on the heart team’s clinical judgment in addition to a combination of scores. Surgery is recommended for patients with AR with a significantly enlarged ascending aorta, severe symptomatic AR, or severe asymptomatic AR with LVEF ≤50% or LV end-diastolic diameter ≥70 mm or LV endsystolic diameter >50 mm (or >25 mm/mm2 body surface area). Transcatheter aortic valve implantation (TAVI) is indicated for patients with severe symptomatic AS not suitable for surgical aortic valve replacement (SAVR) with a life expectancy of >1 year. TAVI should not be performed in patients at intermediate risk for surgery. SAVR is indicated for the following: • • Severe symptomatic AS Patients undergoing coronary artery bypass graft (CABG) surgery, ascending aorta surgery, or other valve surgery
October 2012
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Severe asymptomatic AS with systolic LV dysfunction, abnormal exercise test showing AS-related symptoms, or if low surgery risk and peak transvalvular velocity >5.5 m/s or severe valve calcification and peak transvalvular velocity progression ≥0.3 m/s per year
Mitral valve repair for symptomatic severe primary MR is preferred when it is expected to be durable. For secondary severe MR, surgery is indicated in patients undergoing CABG and who have LVEF >30% and should be considered for patients with LVEF <30%, option for revascularization, and evidence of viability. Third Universal Definition of Myocardial Infarction Joseph S. Alpert, MD, University of Arizona College of Medicine, Tucson, Arizona, USA, presented the ESC third universal definition of MI [Thygesen K et al. Eur Heart J 2012]. Table 2 shows the definitions of the 5 MI classifications. Table. 2. Universal Classification of MI.
Type 1: Spontaneous MI Spontaneous MI related to atherosclerotic plaque rupture, ulceration, fissuring erosion, or dissection with resulting intraluminal thrombosis in ≥1 of the coronary arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis. The patient may have underlying severe CAD but, on occasion, non-obstructive or no CAD. Type 2: MI Secondary to an Ischemic Imbalance In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand (eg, coronary endothelial dysfunction, coronary artery spasm, coronary embolism, tachy-/ brady-arrhythmias, anemia, respiratory failure, hypotension, and hypertension with or without LVH). Type 3: MI Resulting in Death When Biomarker Values Are Unavailable Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB, but death occuring before blood samples could be obtained, before cardiac biomarker could rise, or in rare cases cardiac biomarkers were not collected. Type 4a: MI Related to PCI MI associated with PCI is arbitrarily defined by evlauation of cTn values >5x99th percentile URL in patients with normal baseline values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either (i) symptoms suggestive of myocardial ischemia, or (ii) new ischemic ECG changes or new LBBB, or (iii) angiographic loss of patency of a major coronary artery or side branch or persistent slow or fall of cardiac biomarkers values with at least 1 value above the 99th percentile URL. Type 5: MI Related to CABG MI associated with CABG is arbitrarily defined by elevation of caridac biomarker values >10x99th percentile URL in patients with normal baselines cTn values (99th percentile URL). In addition, either (i) new pathological Q waves or new LBBB, or (ii) angiographic documented new graft or new native coronary artery occlusion, or (iii) imaging evidence of new loss of viable myocardium or new regional all-motion abnormality
CABG=coronary artery bypass grafting; CAD=coronary artery disease; cTn=cardiac troponin; ECG=electrocardiogram; LBBB=left bundle branch block; LVH=left ventricular hypertropy; MI=myocardial infarction; PCI=percutaneous coronary intervention; URL=upper reference limit.
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Table of Contents for the Digital Edition of MD Conference Express ESC 2012
MD Conference Express ESC 2012
Contents
ESC 2012 Clinical Practice Guidelines
TAVI: 10 Years After the First Case
PARAMOUNT Trial Results
TRILOGY ACS Outcomes
Results from the ALTITUDE Trial
Results of the WOEST Trial
Results from the Aldo-DHF Trial
FAME 2 Results
Results from the IABP-SHOCK II Trial
STEMI Mortality Decreases in France While Some Key Risk Factors Increase
Results from the PURE Study
PURE: Treatment and Control of Hypertension
Genetic Determinants of Variability in Dabigatran Exposure
The RE-LY AF Registry
TRA 2°P-TIMI 50 Results
Rivaroxaban of Benefit in STEMI: ATLAS ACS 2-TIMI 51
Ivabradine Effect on Recurrent Hospitalization for HF
CLARIFY: Similar 1-Year Outcomes for Men and Women with Stable CAD
HPS2-THRIVE Study Results
PRoFESS Study Results
Outcomes from the CARDia Trial
Hypertension
Atrial Fibrillation
Heart Failure
MD Conference Express ESC 2012
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