2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation: Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups

Recently, the European Society of Cardiology (ESC) has updated its guidelines for the management of patients with acute coronary syndrome (ACS) without ST-segment elevation. The current consensus document of the Dutch ACS working group and the Working Group of Interventional Cardiology of the Netherlands Society of Cardiology aims to put the 2020 ESC Guidelines into the Dutch perspective and to provide practical recommendations for Dutch cardiologists, focusing on antiplatelet therapy, risk assessment and criteria for invasive strategy.     

Management of elderly patients with a non-ST-segment-elevation acute coronary syndrome

Elderly patients with an acute coronary syndrome are underrepresented in randomised controlled trials. Neither the European Society of Cardiology nor the American Heart Association/American College of Cardiology acute coronary syndrome guidelines provide specific recommendations for elderly patients. However, elderly patients are at higher thrombotic and bleeding risk compared with younger patients leading to difficulties in choosing the optimal treatment. In this review, we discuss the uncertainties we encounter in treating elderly patients with non-ST-elevation acute coronary syndrome and suggest treatment options based on the existing literature.     

Indications for an early invasive strategy in NSTE-ACS patients

An early invasive strategy in patients who have acute coronary syndrome without ST-elevation (NSTE-ACS) can improve clinical outcome in high-risk subgroups. According to the current guidelines of the European Society of Cardiology (ESC), the majority of NSTE-ACS patients are classified as “high-risk”. We propose to prioritise patients with a global registry of acute coronary events (GRACE) risk score >140 over patients with isolated troponin rise or electrocardiographic changes and a GRACE risk score <140. We also acknowledge that same-day transfer for all patients at a high risk is not necessary in the Netherlands since the majority of Dutch cardiology departments are equipped with a catheterisation laboratory where diagnostic coronary angiography is routinely performed in NSTE-ACS patients. Therefore, same-day transfer should be restricted to true high-risk patients (in addition to those NSTE-ACS patients with very high-risk (VHR) criteria) in centres without coronary angiography capabilities.

     

Management of the patient with an acute coronary syndrome using oral anticoagulation

A significant number of patients with atrial fibrillation, treated with oral anticoagulants, present with an acute coronary syndrome. Many of these patients have an indication for coronary angiography. The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) and the novel P2Y12 inhibitors has generated new uncertainty about the optimal treatment regimen, whether triple or dual therapy should be given and which is the most beneficial P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel). In this article, we will summarise the practical advice on the management of acute coronary syndrome patients requiring oral anticoagulants following the recent consensus document of the European Society of Cardiology (ESC) Working Group on Thrombosis in association with the European Heart Rhythm Association (EHRA) and ESC guidelines.     

Guideline adherence for antithrombotic therapy in acute coronary syndrome: an overview in Dutch hospitals

Objective. To assess current Dutch antithrombotic treatment strategies for acute coronary syndrome (ACS) in light of the current European Society of Cardiology (ESC) guidelines. Methods. For every Dutch hospital with a coronary care unit (CCU) (n = 93) a single cardiologist was interviewed concerning heparin, thienopyridine and GP IIb/IIIa inhibitor (GPI) treatment. In each hospital, we randomly approached one cardiologist assuming equal policy among physicians employed at the same hospital. Results. The response rate was 90%. In 59% of hospitals, treatment of ST-elevation myocardial infarction (STEMI) occurred according to the 2008 ESC STEMI guideline, with unfractionated heparin. In contrast, although not recommended, low-molecular-weight heparin (LMWH) was used in 39% (enoxaparin 19%, dalteparin 12%, nadroparin 8%). In non-STEMI, low-molecular-weight-heparins (LMWHs) were used in 97% of all hospitals. Fondaparinux, agent of choice in a noninvasive strategy for the treatment of non-STEMI, was applied in only 2% of hospitals. Although recommended by the ESC, dose adjustment of LMWH therapy for patients with renal failure is not applied in 71% of hospitals. Likewise, LMWH dose adjustment is not applied for patients aged over 75 years in 92% of hospitals. Conclusion. To a great extent treatment of ACS in the Netherlands occurs according to ESC guidelines. Additional benefit may be achieved by routine dose adjustment of LMWH for patients with renal insufficiency and aged >75 years, since these patients are at high risk of bleeding complications secondary to antithrombotic treatment. Periodical evaluation of real-life practice may improve guideline adherence and potentially improve clinical outcome. (Neth Heart J 2010;18:291-9.)     

Specific recommendations (or lack thereof) for older patients with cardiovascular disease in the current European Society of Cardiology guidelines

Due to population ageing, the number of older and frail patients with cardiovascular disease is increasing. In the current guidelines of the European Society of Cardiology specific recommendations for this older population are missing or scarce, probably due to limited evidence concerning diagnosis and treatment of cardiovascular disease in older patients. Moreover, recommendations on shared decision making, palliative care and advanced care planning are also essential in these guidelines. In this article we evaluate the current European of Society of Cardiology guidelines (2013–2020) to determine whether specific recommendations for older patients have been included.

     

Primary PCI: false positives versus false negatives

Primary percutaneous coronary intervention (PCI) performed within 12 hours after onset of symptoms in acute ST-elevation myocardial infarction (STEMI) is the currently recommended therapy in the guidelines of the European Society of Cardiology.1 The basis of these recommendations is an array of clinical trials comparing PCI with thrombolysis on short-term as well as long-term follow-up.2 Initially and intuitively larger STEMIs in younger patients were eligible for this therapy, but increasingly also smaller infarcts and older patients have proven to benefit from primary PCI.3 Typically, in centres providing the service of primary PCI in the Netherlands, about a third of the total number of PCIs is now for STEMI.     

Role of prophylactic coronary revascularisation in improving cardiovascular outcomes during non-cardiac surgery: A narrative review

Coronary revascularisation has been a topic of debate for over three decades in patients undergoing high-risk non-cardiac surgery. The paradigm shifted from routine coronary angiography toward stress test guided decision-making based on larger randomised trials. However, this paradigm is challenged by relatively newer data where routine coronary angiography and revascularisation is shown to improve perioperative cardiovascular outcomes. We review major studies performed over a long period including more contemporary data with regard to the 2014 American College of Cardiology/American Heart Association as well as 2014 European Society of Cardiology guideline on perioperative cardiovascular evaluation of patients undergoing non-cardiac surgery.     

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called ‘endocarditis team’ in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

     

Invasive coronary physiology: a Dutch tradition

Invasive coronary physiology has been applied since the early days of percutaneous transluminal coronary angioplasty, and has become a rapidly emerging field of research. Many physiology indices have been developed, tested in clinical studies, and are now applied in daily clinical practice. Recent clinical practice guidelines further support the use of advanced invasive physiology methods to optimise the diagnosis and treatment of patients with acute and chronic coronary syndromes. This article provides a succinct review of the history of invasive coronary physiology, the basic concepts of currently available physiological parameters, and will particularly highlight the Dutch contribution to this field of invasive coronary physiology.

     

Dutch guidelines for interventional cardiology: institutional and operator competence and requirements for training

Interventional cardiology is an expanding field within cardiovascular medicine and today it is generally accepted that cardiologists require specific training, knowledge and skills. Hospitals where coronary interventions are performed must be properly equipped and able to provide specialised care. Percutaneous coronary interventions are frequently used for coronary revascularisation. The public should have confidence in the uniformity of high quality care. Therefore, such quality of care should be maintained by certification of the individual operators, general guidelines for institutional requirements and formal audits. The Netherlands Society of Cardiology (NVVC) will be implementing a new registration system for cardiologists with a subspecialisation that will include registration for interventional cardiology. The NVVC asked the Working Group of Interventional Cardiology (WIC) to update the 1994 Dutch guidelines on operator and institutional competence, and requirements for training in interventional cardiology in order to incorporate them into the official directives. The present guidelines represent the expert opinion of the Dutch interventional cardiology community and are in accordance with international regulations.After two rounds of discussion, the NVVC approved the guidelines in November 2004 during the autumn meeting.     

How to target uncertainty in Dutch invasive cardiovascular care

Current meetings of the Netherlands Society of Cardiology and the Working Group on Intervention Cardiology have shown that new strategic developments in the Dutch healthcare system have created much turbulence and uncertainty amongst members of the organisations. Both on-site and off-site new cardiac centres with and without surgical backup, respectively, are arising or being planned throughout the Netherlands. These strategic adaptations are related to service delivery failure, despite appropriate quality measures. To understand the reasoning behind this uncertainty and how to deal with it, we need to explore its origin and thinking. Its rationale is based on the assumption that each organisation relies on its ability to survive through innovation and transformation. Cardiologists and cardiac surgeons are key players in a large group of stakeholders participating in the chain of cardiovascular care. In addition, the Dutch healthcare system is deeply embedded in a historical sociopolitical environment. This may explain why ongoing uncertainty may beget more uncertainty. What are the consequences for the content of the route forward?     

Debate: When should we intervene in unstable angina - Time for an old look?

Current treatment modalities for patients with acute coronary syndromes center on early diagnosis, risk stratification and, increasingly, early treatment including invasive approaches. The appropriate timing of these invasive modalities in the context of the overall treatment program remains an area of controversy. Specifically, studies in the past recommended a period of medical 'stabilization' while current approaches are considerably more aggressive. The potential hazard of early intervention, in particular, has not properly been weighed against the benefit. This article hopes to provide a framework for examining the appropriate timing of intervention, specifically percutaneous coronary intervention, in acute coronary syndromes.     

Genetic diagnostics and genetic counselling in Hypertrophic Cardiomyopathy (HCM)

Dutch professional groups involved in drawing up this guideline: cardiologists, paediatric cardiologists, clinical geneticists, clinical molecular geneticists, genetic counsellors, psychosocial workers, associated with or cooperating with the university hospitals’ outpatient clinics for cardiogenetics. Approved by the NVVC, VKGN and NVK (paediatric cardiology section). NVVC - Nederlandse Vereniging voor Cardiologie – Dutch Society for Cardiology; VKGN - Vereniging Klinische Genetica Nederland – the Netherlands Society for Clinical Genetics; NVK - Nederlandse Vereniging Kindergeneeskunde – Dutch Society for Paediatrics. First published in Dutch in June 2009.     

Major achievements in cardiology in the past century: influence on Dutch cardiovascular medicine

At the occasion of the 75th anniversary of the Netherlands Society of Cardiology, it is interesting to look back on the major scientific achievements in cardiovascular medicine of the last century and to pay attention to the impact of these achievements on Dutch Cardiology. It might be a nice opportunity not only to mention the ten great discoveries in Cardiology in the past century, but also to address the pioneering work in the Netherlands. When honouring and paying tribute to Dutch individuals, this special article only refers to emeriti-professors in cardiology (and some other closely-related retired experts), as this is a historical reflection rather than a cross-sectional view of current attainments. The practising pioneers of today will hopefully be remembered in 75 years from now. (Neth Heart J 2009;17:136–9.)     

Pre-hospital management,procedural performance and outcomes for primary percutaneous coronary intervention in ST-elevation myocardial infarction in the Netherlands: Insights from the Dutch cohort of the APPOSITION-III trial

Aim

The aim of this study was to achieve useful insights into pre-hospital management and procedural performance for ST-elevation myocardial infarction (STEMI) in the Netherlands by extrapolating patient characteristics, and procedural and clinical outcomes of the Dutch patient cohort from the APPOSITION-III trial.

Methods

This is a retrospective analysis from the APPOSITION-III trial with respect to the geographical borders of STEMI management. The APPOSITION-III trial was a European registry for the use of the STENTYS self-expandable stent in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). 965 Patients were enrolled mainly in the Netherlands (n = 420, 43.5?% of the overall study population), Germany (n = 165) and France (n = 131). The data from the Dutch cohort were compared with both the overall study population, and the French and German cohorts, respectively, as well as the European Society of Cardiology (ESC) STEMI guidelines.

Results

In this trial there was a wide inter-country variation on symptom-to-balloon time, 165 minutes (120–318) in the Netherlands, 270 minutes (180–650) in Germany and 360 minutes (120–480) in France, respectively. In general, a preload of dual antiplatelet therapy (DAPT) combined with heparin was more often performed in the Dutch and French cohort than in the German cohort. DAPT at discharge was high across the whole APPOSITION-III population. No important differences were seen between the different groups according to the endpoints major adverse cardiac event and stent thrombosis.

Conclusion

In the Dutch cohort of an European multicentre STEMI study (APPOSITION-III trial), the performance in terms of symptom-to-balloon time, and pre-, peri- and post-procedural medical treatment is in line with the recommendations of ESC STEMI guidelines.

     

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial)

BACKGROUND: Although percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery.Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction. METHODS: The VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care).The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years. CONCLUSION: The primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction.     

Fostering diffusion of scientific contents of National Society Cardiovascular Journals:the new ESC search engine

European Society of Cardiology (ESC) National Society Cardiovascular Journals (NSCJs) are high-quality biomedical journals focused on cardiovascular diseases. The Editors’ Network of the ESC devises editorial initiatives aimed at improving the scientific quality and diffusion of NSCJ. In this article we will discuss on the importance of the Internet, electronic editions and open access strategies on scientific publishing. Finally, we will propose a new editorial initiative based on a novel electronic tool on the ESC web-page that may further help to increase the dissemination of contents and visibility of NSCJs.     

29th Congress of the European Society of Cardiology

The Editorial Board of the Netherlands Heart Journal is very pleased to present its annual supplement on this year’s meeting of the European Society of Cardiology (ESC) Congress of Cardiology, held in Vienna from 1 – 5 September 2007.