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Acute Cardiovascular Care 2015 Vienna

New ESC Grants for Medical Research Innovation

XXI. World Congress of Echocardiography and Cardiology

“Ten Commandments” of 2015 ESC Infective Endocarditis Guidelines

“Ten Commandments” of 2015 ESC Acute Coronary Syndromes Guidelines

“Ten Commandments” of 2015 ESC Pericardial Diseases Guidelines

“Ten Commandments” of 2015 ESC Pulmonary Hypertension Guidelines

“Ten Commandments” of 2015 ESC Ventricular Arrhythmias and Prevention of SCD Guidelines 


Acute Cardiovascular Care conference will highlight innovations and controversies

Acute Cardiovascular Care 2015 will be held 17 - 19 October 2015 in Vienna, Austria at the HOFBURG Vienna Congress Centre. It is the annual meeting of the Acute Cardiovascular Care Association (ACCA), a registered branch of the European Society of Cardiology (ESC).

Prof Kurt Huber, Chairperson of the Scientific Programme Committee stated “The main theme this year is innovations in acute cardiovascular care.  Novelties will be presented and discussed through the abstracts and symposia. E.g. in a session on innovations in acute heart failure, experts will present the latest data on new treatments such as vasodilator therapy, ventricular-arterial coupling, an interatrial decompression device, and mechanical support.”

Controversies in clinical practice that are heavily discussed among physicians will include:

  • pre-hospital treatment of patients with ACS,
  • the use of bivalirudin versus heparin during primary PCI,
  • thrombus aspiration in patients with STEMI,
  • the early management after, out of hospital cardiac arrest.

Antiplatelet therapy in ACS patients is a hot topic and research will be revealed on the duration of dual antiplatelet therapy. Biomarkers are a rapidly evolving area and new rule-in and rule-out strategies in MI using high sensitive troponin assays and the new marker copeptin will be debated.

Treatment of pulmonary embolism and DVT with non-vitamin K antagonist oral anticoagulants (NOACs), will be included in the programme for the first time this year.

Other crucial topics have been added to the scientific programme such as antithrombotic therapy, atrial fibrillation, treatment of bleeding, interventional cardiology, pacemakers and ICDs, external heart pumps, and stroke systems of care.

A novel ESC position paper on the pre-hospital management of chest pain and dyspnoea will be distributed during the meeting. (1)  

First author Professor Farzin Beygui said: “The position paper is the first symptom based paper ever published on the subject covering the wide spectrum of acute cardiovascular conditions that may cause chest pain or dyspnoea.”

“Its aim is to provide guidance which may be applicable in all European countries despite the variety of emergency medical services (EMS), for pre-hospital management, based on evidence where available or expert opinion and consensus.”

The paper may provoke controversy over its recommendation for physician based EMS. Unlike most EMS worldwide, the majority of EMS in Europe are physician-based. Because a high level of pre-hospital care may require emergency physicians on scene, the paper recommends a physician-based EMS organisation with the availability of emergency physicians in the case of chest pain or acute dyspnoea of suspected cardiac origin.

“This point is based on expert consensus and not striking evidence,” said Professor Beygui. “The presence of a physician may improve pre-hospital diagnosis (ultrasound), allow higher rates of reperfusion therapy especially by pre-hospital fibrinolysis, provide higher levels of competence for treating life threatening conditions and more accurate identification of the destination for patient transfer.”

The three day event features over 45 sessions with lectures from global leaders and breaking results in the abstract-based programme. More than 1 000 cardiologists, emergency physicians, intensive care physicians, internists, surgeons, imaging specialists, interventionists, nurses, paramedics and students from nearly 80 countries are expected.

State-of-the-art advances in emergency cardiac care are set to be unveiled, making it an event not to be missed.

The scientific programme is available here


(1)Beygui FCastren MBrunetti NDRosell-Ortiz FChrist MZeymer UHuber KFolke FSvensson LBueno HVan't Hof ANikolaou NNibbe LCharpentier SSwahn ETubaro MGoldstein P. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care. 2015 Aug 27. http://acc.sagepub.com/content/early/2015/08/27/2048872615604119.full

New ESC Grants for Medical Research Innovation

The ESC announced the launch of its new ESC Grants for Medical Research Innovation, at the opening of the ESC Congress 2015 in London. An ambitious programme sponsored exclusively by Böhringer Ingelheim, is aimed at stimulating worldwide research in cardiovascular medicine.

“This grant project is a reflection of the ESC’s commitment to encouraging new and innovative research aimed at improving patient outcomes in thromboembolic disease – a leading cause of mortality worldwide,” said Professor Francesco Cosentino, chair of the programme’s scientific committee. “It is estimated that one in four people die as a result of thromboembolic disease and more research into this disorder is urgently needed,” he said.

The programme, offers four grants, to a maximum of €400,000 each, which will be awarded to independent interventional and observational research projects in the areas of atrial fibrillation, stroke, deep vein thrombosis/pulmonary embolism, percutaneous coronary intervention, coronary artery disease and/or peripheral artery disease.

“We are excited about this initiative because it is a great opportunity to perform important studies aiming for a better understanding of novel therapeutic strategies in this setting,” said Prof. Cosentino. “We are now ready to receive applications from around the world for these prestigious grants - until the November 1st deadline - and look forward to announcing the four winners at European Heart House on December 1st following live presentations by all finalists.”

Eligible research should run no longer than 18 months and have publishable outcomes to be presented at ESC Congress 2017.

Applications may be made via this dedicated webpage: www.escardio.org/innovationgrants


XXI. World Congress of Echocardiography and Cardiology 

The XXI. World Congress of Echocardiography and Cardiology will take place 20-22 November, 2015, in Istanbul, Turkey. The organisers are arranging a high quality scientific program with contributions from world renowned physicians and scientists in the fields of Cardiology, Cardiovascular Surgery and Echocardiography.

The Congress will be held at the Istanbul Lutfi Kirdar Convention and Exhibition Centre (ICEC), located in the heart of congress valley in downtown Istanbul. It is within walking distance of many different category hotels and shopping sites.

Istanbul maintains a distinguished position among the world metropolitan areas, with its unique location between two continents, together with its cultural heritage spanning thousands of years. As one of the most energetic cities in the world, Istanbul continually grows as a center of attraction, representing a contrast in harmony and presenting a breath-taking choice of sights, smells and tastes that everyone must experience at least once in a lifetime. Thus, we believe getting together in such a charming atmosphere with our colleagues is an opportunity nobody should miss.

Hosting this congress in Istanbul -where Asia meets Europe- will not only help us enhance patient care but also build bridges between participants from various countries.

We look forward to welcoming physicians in Istanbul, during November, 2015.

Prof. M. Serdar Küçükoğlu
XXI. World Congress of
Echocardiography and Cardiology

Prof. Navin Nanda
International President


XXI. World Congress of
Echocardiography and Cardiology




Two sets of “Ten Commandments” are presented with some overlap for this very serious condition, Infective Endocarditis, which has a grave prognosis and mortality even in the 21st century.

“Ten Commandments” presented by ESC Task Force member Barbara JM Mulder MD

  1. Antibiotic prophylaxis should be restricted to highest-risk patients, but preventive measures should be maintained or extended, to all patients with cardiac disease.
  2. Echocardiography (TTE and TOE), positive blood cultures and clinical features remain the cornerstone for the diagnosis of IE and new imaging modalities (MRI, CT, PET/CT) may allow the diagnosis of embolic events and of cardiac involvement when TTE/TOE are negative or doubtful.
  3. Prognostic assessment at admission, using simple clinical, microbiological, and echocardiographic parameters, should be used to select the best initial approach; patients with persistently positive blood cultures after 48–72 h of starting antibiotics have a worse prognosis.
  4. Heart failure is the most frequent and among the most severe complication of IE and is an indication for early surgery in native and prosthetic valve endocarditis, even in patients with cardiogenic shock.
  5. Uncontrolled infection is most frequently related to peri-valvular extension or ‘difficult-to-treat’ organisms and is an indication for early surgery.
  6. The risk of embolism is highest during the first 2 weeks of antibiotic therapy and the decision to operate early to prevent embolism should depend on size and mobility of the vegetation, previous embolism, type of microorganism, and duration of antibiotic therapy.
  7. After a first neurological event, cardiac surgery, if indicated, is generally not contraindicated, except when extensive brain damage or intracranial haemorrhage is present.
  8. Recurrences are rare following IE, and may be associated with inadequate initial antibiotic therapy, resistant microorganisms, a persistent focus of infection, intravenous drug abuse, and chronic dialysis.
  9. Complicated and staphylococcal prosthetic valve endocarditis are associated with a worse prognosis and must be managed aggressively; patients with non-complicated, non-staphylococcal late prosthetic valve endocarditis can be managed conservatively with close follow-up.
  10. Cardiac device-related IE must be suspected in the presence of frequently misleading symptoms: prognosis is poor, probably because of its frequent occurrence in elderly patients with associated comorbidities and must be treated by prolonged antibiotic therapy and device removal.

Barbara JM Mulder MD

ESC Task Force member



“Ten Commandments” presented by ESC Task Force member, co-chair and chair.

  1. Creation of an “Endocarditis Team”. A multidisciplinary approach is mandatory, to include cardiologists, cardiac surgeons and specialists of infectious diseases.
  2. The creation of referral Endocarditis Centres is recommended due to the severity of the disease. Centres with experience in complex surgery are the best place to treat such patients.
  3. While echocardiography plays a key role in diagnostic algorithms, the need for a multimodality imaging approach for diagnosing endocarditis is highlighted. The new guidelines show the important diagnostic role of other imaging techniques, such as PET-CT that may be helpful in diagnosis and management decisions.
  4. The Early strategy in endocarditis is crucial:
    1. Early diagnosis,
    2. Early antibiotic therapy,
    3. Early surgery.
  5. Repeat TTE and /or TOE examination is recommended within 5–7 days in case of initially negative examination when clinical suspicion of IE remains high, or as soon as a new complication of IE is suspected (new murmur, embolism, persisting fever, heart failure, abscess, atrioventricular block).
  6. Prophylaxis is still controversial. Antibiotic prophylaxis should be considered for patients at highest risk for IE with a IIa recommendation. It should be considered in:

i) Patients with any prosthetic valve, including transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair.

ii) Patients with previous episode of IE.

iii) Patients with congenital heart disease:

a) Any type of cyanotic congenital heart disease or 

b) Any type of congenital heart disease repaired with a prosthetic material.

  1. New antibiotic strategies were proposed in staphylococcal endocarditis. A consensus was difficult to obtain in the subgroup of patients with the most severe form of IE. Ongoing studies on this topic will be useful.
  2. Urgent surgery in specialised Centres is recommended in cases with aortic or mitral native valve endocarditis (NVE) or prosthetic valve endocarditis (PVE) with severe regurgitation or obstruction causing symptoms of heart failure or echocardiographic signs of poor haemodynamic tolerance, must by treated by urgent surgery. It is also recommended in patients with locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) or in infections caused by fungi or multiresistant organisms. Patients with aortic or mitral NVE or PVE with persistent vegetations >10 mm after ≥1 embolic episode despite appropriate antibiotic therapy must also be treated by urgent surgery.
  3. Special mention is made related to endocarditis in patients with cardiac devices (CDRIE). Prolonged (i.e. before and after extraction) antibiotic therapy and complete hardware (device and leads) removal are recommended. Percutaneous extraction is recommended in most patients with CDRIE, even those with vegetations >10 mm. In these patients routine antibiotic prophylaxis is recommended before device implantation.
  4. Related to patients with neurological complications. After a silent embolism or transient ischaemic attack, cardiac surgery, if indicated, is recommended without delay.

José Luis Zamorano MD

ESC Task Force member


Gilbert Habib MD

ESC Task Force Chairperson

Patrizio Lanzelloti MD

ESC Task Force co-Chairperson

“Ten Commandments” of 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in patients presenting without Persistent ST-Segment Elevation (NSTE-ACS)

  1. "Similar to the 0 h and 3 h protocol”, a rapid rule-out and rule-in protocol for myocardial infarction (MI) at 0 h and 1 h is recommended if a high-sensitivity troponin test with a validated 0 h/1 h algorithm is available. 
  2. Echocardiography is recommended to evaluate regional and global left ventricular (LV) function and to rule in or rule out differential diagnoses.
  3. A P2Y12 inhibitor is recommended in addition to aspirin for 12 months, unless there are contraindications such as excessive risk of bleeds. 
  4. Ticagrelor is recommended for all patients at moderate to high risk of ischaemic events (e.g. elevated cardiac troponins), regardless of initial treatment strategy.
  5. Prasugrel is recommended in patients who are proceeding to percutaneous coronary intervention (PCI).
  6. Clopidogrel is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation.
  7. Antithrombotic strategies for patients requiring oral anticoagulation should be personalized, and the different combinations of oral anticoagulants with single or dual antiplatelet therapy and their variable duration be tailored on the basis of the patient's bleeding risk and management strategy. 
  8. An immediate invasive strategy (<2 h) is recommended in patients with at least one of the following very-high-risk criteria:

Haemodynamic instability or cardiogenic shock,
Recurrent or ongoing chest pain,
Refractory to medical treatment,
Life-threatening arrhythmias or cardiac arrest,
Mechanical complications of MI,
Acute heart failure with refractory angina or ST deviation,
Recurrent dynamic ST- or T-wave changes, particularly with intermittent ST elevation.

  1. An early invasive strategy (<24 h) is recommended in patients with at least one of the following high-risk criteria:

Rise or fall in troponin compatible with MI,
Dynamic ST- or T-wave changes (symptomatic or silent),
Registry of Acute Coronary Events (GRACE) score >140.

  1. An invasive strategy (<72 h) is recommended in patients with at least one of the following intermediate risk criteria:

Diabetes mellitus renal insufficiency (eGFR <60 mL/min/1.73 m2),
LV ejection fraction <40% or congestive heart failure,
Early post-infarction angina,
Recent PCI,
Prior coronary artery bypass grafting (CABG),
Global GRACE risk score >109 and <140,
Or, in the presence of recurrent symptoms or ischaemia on non-invasive testing.

  1. In centres experienced with radial access, a radial approach is recommended for coronary angiography and PCI. It is recommended that centres treating ACS patients implement a transition from transfemoral to transradial access. 
  2. In patients with multivessel coronary artery disease, it is recommended to base the revascularisation strategy (e.g. ad hoc culprit-lesion PCI, multivessel PCI, CABG) on the clinical status and comorbidities as well as the disease severity (including distribution, angiographic lesion characteristics, SYNTAX score) according to the local Heart Team protocol.
  3. It is recommended to start high-intensity statin therapy as early as possible unless contraindicated, and maintain it long-term.

Marco Roffi MD FESC
ESC Task Force chair
Division of Cardiology, University Hospital
Geneva, Switzerland
corresponding author


Carlo Patrono MD
ESC Task Force co-chair
Istituto di Farmacologia
Università Cattolica del Sacro Cuore
Rome, Italy

The “Ten Commandments” of the ESC Guidelines 2015 for Diagnosis and Management of Pericardial Diseases

1.   Hospital admission is recommended for high risk patients with acute pericarditis, defined by a risk factor of either predictor of a specific cause (non-viral or non-idiopathic) or of increased risk of complications.

At least one risk factor among: high fever (>38ºC), subacute course, large pericardial effusion, cardiac tamponade, failure to respond to non-steroidal anti-inflammatory drug (NSAID) therapy; myopericarditis, immunosuppression, trauma or oral anticoagulant therapy.

2.   Colchicine is recommended as a first line therapy for acute pericarditis as an adjunct to aspirin/NSAID therapy.

3.   Pericardiocentesis, or surgical drainage, is indicated for cardiac tamponade, or for symptomatic moderate to large pericardial effusions which do not respond to medical therapy and for suspicion of bacterial or neoplastic aetiology.

4.   The mainstay of treatment for chronic permanent constriction is pericardiectomy.

5.   A general diagnostic work-up should be performed to identify causes that require targeted therapies.  A modern approach for the management of pericardial diseases should include the integration of biological markers, as well as different imaging modalities.

6.   Routine viral serology is not recommended in acute pericarditis, with the possible exception of HIV and HCV.  For the definite diagnosis of viral pericarditis, a comprehensive work-up of histological, cytological, immunohistological and molecular investigations in pericardial fluid should be considered.  In the absence of such argument the term “presumed viral pericarditis” should be used.

7.   In patients living in non-endemic areas, empiric anti-tuberculosis treatment is not recommended when systematic investigation fails to yield a diagnosis of tuberculous pericarditis. By contrast, in patients living in endemic areas empiric antituberculosis chemotherapy is recommended for exudative pericardial effusion, after excluding other causes.

8.   Effective pericardial drainage is recommended for purulent pericarditis as well as administration of intravenous antibiotics.

9.   Cytological analyses of pericardial fluid are recommended for the confirmation of malignant pericardial disease. Pericardial or epicardial biopsy should be considered for the confirmation of malignant pericardial disease.

10.   Aspirin is not recommended for therapy of acute pericarditis in children but NSAIDs at high doses are recommended as first line therapy.

For more information see: http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/essential-message-slideset.aspx

Philippe Charron MD PhD
ESC Task Force co-chair
First and corresponding author

Yehuda Adler MD MHA
ESC Task Force co-chair

The “Ten Commandments” of the 2015 ESC-ERS Guidelines on Pulmonary Hypertension

  1. Right heart catheterization is recommended to confirm the diagnosis of pulmonary arterial hypertension (PAH - Group 1) and to support treatment decisions
  2. Vasoreactivity testing performed during right heart catheterization is recommended in patients with idiopathic PAH, inherited PAH and PAH induced by drugs or toxin use, to detect patients who can be treated with high doses of a calcium channel blocker
  3. It is recommended to evaluate the severity of PAH patients with a panel of data derived from clinical assessment, exercise tests, biochemical markers, and echocardiographic and haemodynamic evaluation and to perform regular follow-up assessments every 3-6 months in stable patients.
  4. It is recommended to avoid pregnancy in patients with PAH
  5. It is recommended for referral centres to provide care by a multi-professional team (cardiology and respiratory medicine physicians, clinical nurse specialist, radiologists, psychological and social work support, with appropriate on-call expertise)
  6. Initial drug monotherapy or initial oral drug combination therapy is recommended in treatment naïve, low or intermediate risk patients with PAH
  7. Sequential drug combination therapy is recommended in PAH patients with inadequate treatment response to initial monotherapy or to initial oral drug combination therapy.
  8. Initial combination therapy including an intravenous prostacyclin analogue is recommended in high risk PAH patients
  9. The use of PAH approved therapies is not recommended in patients with pulmonary hypertension due to left heart disease or lung diseases
  10. Surgical pulmonary endarterectomy in deep hypothermia circulatory arrest is recommended for patients with chronic thrombo-embolic pulmonary hypertension [CTEPH] and it is recommended that the assessment of operability and decisions regarding other treatment strategies (drugs therapy or balloon pulmonary angioplasty) be made by a multidisciplinary team of experts

Nazzareno Galiè MD
ESC Task Force chairperson

Marc Humbert MD PhD
ERS Task Force chairperson

“Ten Commandments” of the 2015 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and Prevention of Sudden Cardiac Death

  1. Investigate individuals with known or suspected ventricular arrhythmias completely, applying both non-invasive and invasive techniques: a good etiological diagnosis is the first step towards efficient management of patients and the prevention of sudden cardiac death.
  2. Perform a complete autopsy in victims of sudden unexplained death, especially when they are young: the identification of an inheritable disease as the cause of death may prevent other tragedies within their family.
  3. Consider the use of an implantable cardioverter defibrillator (ICD) in all survivors of an episode of ventricular fibrillation or ventricular tachycardia accompanied by haemodynamic instability that occurs without apparent reversible causes or outside of the acute phase of myocardial infarction. These patients have a high incidence of recurrent life-threatening arrhythmias.
  4. Ensure that patients with STEMI acute coronary syndromes and unstable angina are urgently sent to reperfusion, especially when recurrent ventricular tachycardia and ventricular fibrillation are present: reducing delays from first medical contact to reperfusion helps prevent sudden cardiac death.
  5. Evaluate left ventricular ejection fraction both before discharge and 6–12 weeks after myocardial infarction: post-MI patients may benefit from ICD implantation for the primary prevention of sudden cardiac death.
  6. Implement optimal therapy including pharmacological agents (ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists) and, if appropriate, ICDs in patients with heart failure with severe systolic dysfunction (left ventricular ejection fraction ≤35%).
  7. Consider the addition of cardiac resynchronization therapy for patients with the previous characteristics, when they also have intraventricular conduction delays with left bundle branch block appearance and QRS duration of >120 ms.
  8. Updated diagnostic criteria for inherited arrhythmogenic syndromes, including Long QT Syndrome and Brugada Syndrome, have been proposed by the new guidelines. Please refer to them in your clinical practice.
  9. Consider catheter ablation in experienced centres as a valuable tool to treat patients presenting scar-related ventricular tachycardias, bundle branch re-entrant tachycardia or electrical storms.
  10. Discuss with your patients the issues related to the impact that ICDs may have on their quality of life, before the implant and during their disease progression. Consider the possibility of deactivating the ICD when their clinical conditions deteriorate. Always respect your patients’ autonomy.

Andrea Mazzanti MD
Molecular Cardiology
IRCCS Salvatore Maugeri Foundation



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