Focus on prevention, diagnosis and management of cardiovascular diseases

Exciting questions and current research findings related to heart health were discussed at this year’s ESC. The main focus was on prevention strategies, diagnostics and the management of cardiovascular diseases. Current guideline recommendations also support the cardiology approach.

It’s finally here, the long-awaited heart failure guideline. Management needs significant optimization, as affected patients require hospitalization on average once a year and more than half die within five years. Therefore, tests for natriuretic peptides are recommended when heart failure is suspected. If they are elevated, an echocardiogram should be connected to clarify the underlying cardiac problem. There is another innovation regarding stratification: patients with an ejection fraction between 41 and 49% are now classified as “mildly reduced” heart failure with reduced ejection fraction. The reason for this change was the growing evidence that patients with HFmrEF appear to benefit from HFrEF treatments to a similar extent as HFrEF patients themselves. Accordingly, the treatment recommendations differ little from those for HFrEF, with the exception that SGLT2 inhibitors are not listed at all and all other agents apart from diuretics are listed only with a class IIb C recommendation.

Patients with reduced ejection fraction (≤40%) will be treated with a Simplified Algorithm in the future. Accordingly, every HFrEF patient should receive an ACE inhibitor (ACE-I) or angiotensin receptor neprilysin inhibitor (ARNI), a beta blocker, a mineral corticoid receptor antagonist (MRA), and an SGLT2 inhibitor (dapagliflozin or empagliflozin)-all four agents have a class IA recommendation. It is up to the physician to decide which of the four agents listed should be prescribed first. Treatment with these four key medications should be started as soon and safely as possible. Anything beyond that should be tailored to the particular heart failure phenotype. Regarding the treatment of HFpEF, the guideline is still at the same level as five years ago: No drug is recommended to improve prognosis due to lack of evidence.

Cardiovascular disease prevention

The guideline on the prevention of cardiovascular disease also presented itself in a new guise, as new possibilities for risk prediction, assessment of the benefit of therapy, and new therapeutic options are now available. Of central importance for preventive measures is the assessment of cardiovascular risk. The most important risk factors are high LDL cholesterol levels, high blood pressure, cigarette smoking, diabetes mellitus and obesity. Step by step, for example, smoking cessation, a healthy lifestyle and a systolic blood pressure below 160 mmHg should then be implemented in healthy people. Adults of all ages should engage in at least 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity physical activity per week. In addition, the recommendation to reduce time spent sitting and to incorporate at least light activity throughout the day is new. In obese individuals at high risk for cardiovascular disease, bariatric surgery should be considered if appropriate diet and exercise do not result in sustained weight loss.

Reduce events and mortality in diabetes patients

Patients with type 2 diabetes and mild to moderate kidney disease benefit from treatment with finerenone. The first newly approved nonsteroidal selective mineralocorticoid receptor (MR) antagonist can significantly reduce cardiovascular events as well as cardiovascular mortality, according to results from the FIGARO-DKD trial. Under finerenone, the cardiovascular event rate was 13% lower than under placebo. About 40% of all patients with type 2 diabetes develop chronic kidney disease. However, most of them die as a result of cardiovascular disease or infections before they need renal replacement therapy. In the trial, 7437 patients received either finerenone (10 mg or 20 mg) or placebo in addition to standard therapy with maximally tolerated RAS blockade. The primary study end point was a cardiovascular composite (duration to cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure). This endpoint occurred during a mean observation period of 3.4 years in 458 (12.4%) patients in the finerenone group and in 519 patients (14.2%) in the placebo group, for a relative risk reduction of 13%.

Congress: ESC 2021