The European Society of Cardiology (ESC) has issued new guidelines, published online today in the European Heart Journal and on the ESC website, for the management of congenital heart disease and for acute coronary syndromes in patients presenting without persistent ST-segment elevation.
“Having a congenital heart disease, with a need for long-term follow-up and treatment, can also have an impact on social life, limit employment options and make it difficult to get insurance,” said Helmut Baumgartner, Chairperson of the ESC’s guidelines Task Force and head of Adult Congenital and Valvular Heart Disease at the University Hospital of Münster, Münster, Germany. “Guiding and supporting patients in all of these processes is an inherent part of their care.”
All adults with congenital heart disease should have at least one appointment at a specialist centre to determine how often they need to be seen. Teams at these centres should include specialist nurses, psychologists and social workers given that anxiety and depression are common concerns.
Pregnancy is contraindicated in women with certain conditions such high blood pressure in the arteries of the lungs.
“Pre-conception counselling is recommended for women and men to discuss the risk of the defect in offspring and the option of foetal screening,” said Professor Julie De Backer, Chairperson of the guidelines Task Force and cardiologist and clinical geneticist at Ghent University Hospital, Ghent, Belgium.
Concerning sports, recommendations are provided for each condition. Professor De Backer said: “All adults with congenital heart disease should be encouraged to exercise, taking into account the nature of the underlying defect and their own abilities.”
The guidelines state when and how to diagnose complications. This includes proactively monitoring for arrhythmias, cardiac imaging and blood tests to detect problems with heart function.
Detailed recommendations are provided on how and when to treat complications. Arrhythmias are an important cause of sickness and death and the guidelines stress the importance of correct and timely referral to a specialised treatment centre. They also list when particular treatments should be considered such as ablation (a procedure to destroy heart tissue and stop faulty electrical signals) and device implantation.
For several defects, there are new recommendations for catheter-based treatment. “Catheter-based treatment should be performed by specialists in adult congenital heart disease working within a multidisciplinary team,” said Professor Baumgartner.
Non-ST-segment elevation acute coronary syndrome
For non-ST-segment elevation acute coronary syndrome, ESC notes that treatment is aimed at the underlying cause. The main reason is fatty deposits (atherosclerosis) that become surrounded by a blood clot, narrowing the arteries supplying blood to the heart. In these cases, patients should receive blood thinners and stents to restore blood flow. For the first time, the guidelines recommend imaging to identify other causes such as a tear in a blood vessel leading to the heart.
Regarding diagnosis, there is no distinguishing change on the electrocardiogram (ECG), which may be normal. The key step is measuring a chemical in the blood called troponin. When blood flow to the heart is decreasedor blocked, heart cells die, and troponin levels rise. If levels are normal, the measurement should berepeated one hour later to rule out the diagnosis. If elevated, hospital admission is recommended to further evaluate the severity of the disease and decide the treatment strategy.
Given that the main cause is related to atherosclerosis, there is a high risk of recurrence, which can also be deadly. Patients should be prescribed blood thinners and lipid lowering therapies. “Equally important is a healthy lifestyle including smoking cessation, exercise, and a diet emphasising vegetables, fruits and whole grains while limiting saturated fat and alcohol,” said Jean-Philippe Collet, Chairperson of the guidelines Task Force and professor of cardiology, Sorbonne University, Paris, France.
Behavioural change and adherence to medication are best achieved when patients are supported by a multidisciplinary team including cardiologists, general practitioners, nurses, dietitians, physiotherapists, psychologists, and pharmacists.
The likelihood of triggering another heart attack during sexual activity is low for most patients, and regular exercise decreases this risk. Healthcare providers should ask patients about sexual activity and offer advice and counselling. Annual influenza vaccination is recommended – especially for patients aged 65 and over – to prevent further heart attacks and increase longevity.
“Women should receive equal access to care, a prompt diagnosis, and treatments at the same rate and intensity as men,” said Holger Thiele, Chairperson of the guidelines Task Force and medical director, Department of Internal Medicine/Cardiology, Heart Centre Leipzig, Germany.