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Valve Atlas for iPad
New: EHJ Podcast

Dual antiplatelet treatment no benefit after 1 year from stenting
BCS 'A Year in Cardiology – 2014'
Blood pressure control
Roads and sudden cardiac death
ESC launches new journal
Study results of new stent
New ESC President statement
Jose Roelandt death
Tour de Coeur - Tour Diary
The new ESC journal EHJs
The “Ten Commandments” of ESC Guidelines 2014

Clinical Atlas of Transcatheter Aortic Valve Therapies launched by PCR

The PCR Valve Atlas on aortic valve replacement has been launched as an iPad app. It contains 9 chapters primarily aimed at junior and intermediate practitioners, with a section on complications that will interest experienced interventionists.

Chapter one is focused on the anatomy of the aortic valve apparatus and shows Professor Robert Anderson (UK) describing human aortas on video.
Chapter two covers relevant imaging modalities with all variations of echocardiography, multi slice computed tomography (MSCT) and angiogram imagery.
The third chapter is a parade of all known valve devices that have a CE mark or are in the development pipeline.

Chapter four is dedicated to procedural concepts using moving images of implantations augmented with a 3D phantom model clearly illustrating the various mannerisms of implantations. This is one of the major novelties of the atlas.

The following chapter, five, is entitled complications and bailout procedures and covers the most common complications (cerebrovascular, MI, vascular, device related, etc), presented at the various PCR meetings across the globe. Each case is richly described and illustrated.

With the increased uptake of TAVI comes a need to interpret and treat failing valves with a
valve-in-valve procedure, and this can be found in chapter six. The last three chapters cover items of interest for parties who wish to start up their own TAVI programmes, including accessory equipment , the functioning of the heart valve team, and material set up lists for the TAVI operating table.

The atlas can be downloaded from the iTunes App Store


The new European Heart Journal Podcast series is launched

The EHJ with Oxford University Press are delighted to announce that Monday 17th November sees the launch of the first episode in the new, free, European Heart Journal podcast series.  The flagship podcast has been published alongside Dr Felix Mahfoud, and Professor Thomas Lüscher’s editorial "Renal denervation: Symply trapped by complexity?", which accompanies the Fast Track article "Predictors of blood pressure response in the SYMPLICITY HTN-3 trial" from David E. Kandzari et al.

The EHJ Podcast series joins the established suite of digital offerings from the EHJ, building pathways for cardiologists to discover and access the high-quality articles published in the Journal. Each podcast will publish in conjunction with a key Hotline Paper providing an audio summary of the article which can be downloaded and listened to for free.

Not only will cardiologists be able to access the EHJ Podcast series via links from the online table of contents and the Hotline Papers themselves, but individual episodes can be downloaded and listened to via podcast managers such as iTunes. You can also subscribe to the series and receive the latest episodes straight to your device.

With the addition of the EHJ Podcast series you can now listen, watch, and read cutting edge research from the EHJ anytime, anywhere.

The podcasts are available at: eurheartj.oxfordjournals.org/podcast


ARCTIC-Interruption trial finds no benefit of DAPT beyond 1 year after stenting

Dual antiplatelet treatment (DAPT) beyond 1 year after drug-eluting stent (DES) implantation provides no benefit and may be harmful in patients with no events in the first year, according to the results of the ARCTIC-Interruption trial.

The trial was a planned extension of the ARCTIC-Monitoring trial, which randomised 2440 patients to a strategy of platelet function testing with antiplatelet treatment adjustment or a conventional strategy after DES implantation. After 1 year, patients with no contraindication to interruption of DAPT were re-randomised to either interruption (624 patients) or continuation (635 patients) of DAPT for a further 6-18 months (ARCTIC-Interruption trial). The primary endpoint was a composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularisation, analysed by intention to treat.

After 17 months, there were no differences between the two groups in the primary endpoint, which occurred in 4% of patients in both groups. STEEPLE major bleeding events were more frequent in the continuation (1%) compared to the interruption group (<0.5%) but the difference was not significant. There were significantly more major or minor bleedings in the continuation (2%) versus the interruption group (1%) (p=0.04).

The trial demonstrates that 1 year after stenting just half of the patients could be randomised leading to selection of a low risk population. No conclusions can be made for high-risk patients as they were not randomised.

The authors recommend that guidelines be revisited in favour of shorter duration of DAPT after stenting.

The article can be found here.


British Cardiovascular Society ‘A Year in Cardiology – 2014’

‘A Year in Cardiology’ is a very popular one-day symposium, which returns to the Royal College of Physicians in London for its fourth year. Held annually at the end of the international conference calendar by the British Cardiovascular Society, it has rapidly become an essential opportunity for cardiologists to update themselves with the year’s most important developments in Cardiology.

The internationally renowned expert faculty will present a comprehensive review of the headline news for the year. The much anticipated keynote lecture this year will be given by Professor Philippe Gabriel Steg, Professor of Cardiology at the Université Paris and Imperial College London, a leading figure in coronary artery disease.

The morning session provides a succinct update on the important ESC and NICE Guideline updates, whilst the afternoon session reviewing key developments in all major cardiology subspecialties. At the end of each session delegates have the opportunity to pose questions to the speakers in the ‘Ask the Expert’ debate.

This year’s conference will be held on Friday 12 December 2014. The symposium is accredited by EBAC with delegates earning 6 CME or CPD for attendance.

For details on ‘A Year in Cardiology - 2014’ and other symposia run by the British Cardiovascular Society please see www.bcs.com/education/.


Doctor visits are greatest predictor of BP control

Visiting a doctor at least twice a year increases likelihood of blood pressure control by more than three-fold compared to one or fewer annual visits.

Visits to the doctor are the greatest predictor of blood pressure control, according to research published in Circulation.

The researchers studied 37,000 adults from the National Health and Nutrition Examination Survey who had their blood pressure checked in 1999-2012. They found that people who visited their doctor at least twice a year were 3.2 times more likely to keep their blood pressure under control than those who saw their doctor once a year or less.

Brent M Egan
Photo courtesy American Heart Association & copyright Greenville Health System

After controlling for diabetes, health insurance, body mass index, smoking and other factors, the investigators found that doctor visits were the strongest predictor of blood pressure control. Having healthcare insurance and getting treated for high cholesterol also increased the likelihood of controlling blood pressure.

Obese people in the study were also more likely to keep their blood pressure under control. This is ‘probably because doctors recognise the need to control risk factors and may be quicker to give them blood pressure medications’, said study author Brent M. Egan (Greenville, South Carolina, US).


Living near major roads may increase risk of sudden cardiac death in women

Living near a major road may increase women’s risk of dying from sudden cardiac death (SCD), according to new research.

On a population level, living near a major roadway was as important a risk factor as smoking, poor diet or obesity.

The researchers studied data from 107,130 women (predominately white, average age 60) who took part in the prospective Nurses’ Health Study from 1986-2012. A total of 523 cases of SCD were identified over 26 years of follow-up. The distance from roadways to homes was calculated.

After adjusting for a large number of factors including age, race, calendar time, cigarette smoking, physical activity and diet, the researchers found that living within 50 metres of a major road increased the risk of SCD by 38% compared to living at least 500 metres away. Each 100 metres closer to roadways was associated with a 6% increased risk for SCD. In the 1,159 cases of fatal coronary heart disease, risk increased by 24%.

The investigators said that the public’s exposure to major roadways was comparable to major SCD risk factors. They added that more research was needed among men and among women of different ages, races and income levels because nearly all participants in the study were middle-age to elderly, white and of middle- to upper-socioeconomic class.

The next step in their research will be to determine what specific exposures, such as air pollution, are driving the association between heart disease and major roadway proximity.

The Circulation paper can be found here.


ESC Launches Journal on Cardiovascular Pharmacotherapy

A new ESC journal on cardiovascular pharmacotherapy was launched at ESC Congress by the ESC and Oxford University Press. European Heart Journal – Cardiovascular Pharmacotherapy officially starts publishing in 2015. The journal’s website went live in September 2014.

Editor in chief Professor Stefan Agewall said: “We aim to become the number one journal in the field of clinical cardiovascular pharmacology within a couple of years.” The journal aims to improve the pharmacological treatment of patients with cardiovascular disease. Four issues will be published in 2015. Prof Agewall said: “The number of issues will increase annually with the goal of producing a monthly publication within 5 to 6 years.”

An expert and respected editorial board has been recruited from across the globe. Prof Agewall brings significant clinical, research and editorial experience to his role as editor in chief. Currently professor and senior consultant in cardiology at Oslo University Hospital and Oslo University in Norway, he has worked in cardiology for 20 years splitting his time between clinics, research and education.


Combo Dual Therapy Stent Findings Presented at TCT Meeting

Prof. Stephen W.L. Lee MD presented two-year optical coherence tomography (OCT) findings and three-year clinical follow up from the EGO COMBO study, showing the healing benefits of the COMBO™ Dual Therapy Stent, a drug eluting stent (DES) with active endothelial projenitor cell (EPC) capture technology. The findings were presented during the 26th Annual Transcatheter Cardiovascular Therapeutics (TCT) meeting, in Washington, D.C., 13-17 September, 2014.

“This is the first study to assess the healing profile of a dual therapy stent by optical coherence tomography,” said Dr Lee of the Queen Mary Hospital, Hong Kong. “The COMBO Stent approach shows early healing benefits and stability over the long-term. The results demonstrate no neoatherosclerosis observed by OCT at 24 months, and no late restenosis or stent thrombosis by 36 months.”

Latest evidence surrounding the COMBO Stent’s active EPC capture was also presented by Prof. Michael Haude, M.D., Lukaskrankenhaus, Neuss, Germany, who demonstrated how the COMBO Stent uses a bound antibody to capture EPCs and promotes accelerated endothelial coverage. The Stent has an abluminal sirolimus drug elution delivered from a biodegradable polymer that is dissipated within 90 days.

Prof. Haude said, “With the dual therapy approach of the COMBO Stent, the abluminal sirolimus release from a bioresorbable polymer matrix controls the restenosis and neointimal proliferation, whilst the luminal surface is coated with an antibody that enables an earlier and more mature healing of the stented lesion. Delayed healing is of continued concern in conventional DES today as it leads to stent thrombosis and in the long-term, to neoatherosclerosis. The COMBO Stent helps to address these concerns and may offer a long-term solution.”

More information at www.OrbusNeich.com.


New ESC President Prof Fausto Pinto Issues Statement

Firstly, a huge thanks to the 30,300 plus participants who travelled from 140 different countries to take part in the ESC Congress 2014, as well the 193,100 health care professionals who followed the latest scientific findings online.

ESC Congress 2014 was an extraordinary event, with important implications for the way we practice and treat patients. Highlights included a major breakthrough in the treatment of heart failure (PARADIGM-HF), the ongoing importance of prevention versus intervention, five new ESC Clinical Practice Guidelines and a new batteryless cardiac pacemaker. All resources from ESC Congress can of course be accessed free in the online library ESC Congress 365.

As I begin my two year Presidency of this hardworking society, there are three major areas in which I hope to build on the way in which it supports you - cardiologists, nurses, allied professionals and all those who strive with us to reduce the burden of cardiovascular disease in Europe and beyond:

  • Education to secure proper dissemination of knowledge, best practices and how to apply them
  • Supporting the young cardiologists in training, who will be the leaders of the future
  • Membership to increase the impact of ESC science, knowledge and expertise around the world

In these goals we must be innovative, strive for excellence, and make a lasting impact. I look forward to working with you, for you, and hope to meet many of you as we take ESC science around the world.

Professor Fausto Pinto, FESC
President, European Society of Cardiology 2014 - 2016


Jose Roelandt Death

The cardiology community was saddened to hear of the death of Professor Jose RTC Roelandt on 31 August 2014. A pioneer and innovator in echocardiography he was born in 1938, received his MD in 1964 and went on to become Cardiology chairman at the Thoraxcentre, Erasmus Medical Centre, Netherlands, in 1987.

Jos as he was known, was an author of over 1000 papers and 19 textbooks, he was the Founding Editor of the European Journal of Echocardiography and editor-in-chief from 1999 till 2010.

During his career he delivered many prestigious lectures, received a number of awards and was an honorary member of many cardiology societies.

The passing of Jos Roelandt is a great loss to European Cardiology and particularly to the echocardiography community. He will be greatly missed but not forgotten.

Tour de Coeur - Tour Diary

Tour de Coeur - First report

The "Tour de Coeur" started from Geneva, Switzerland for the fourth time. Thirty cardiovascular health professionals set off to bicycle to the Annual ESC Congress 2014 in Barcelona, Spain. The 1 week journey is to raise awareness for cardiovascular disease to reduce morbidity and mortality. It is also a fund raiser for the Swiss Heart Foundation to support cardiovascular research projects.

The group was sent off at Geneva University Hospital by Prof. François Mach, head of cardiology and was then accompanied to the French border by many friends and supporters on their bicycles.

The first stop at Lac d’Annecy provided a refreshing dip in the cool water. Their energy restored after a hearty picnic the journey continued along the River Rhone. They arrived at Albertville for the night after 112 km and 979 meters of altitude difference. It was rather a flat first leg.

The coming days will be much tougher with up to 2100 altitude meters to overcome!

Tour de Coeur - second day report

Now in France the second stage of the “Tour de Coeur” is defined by high passes (Cols), best known from the Tour de France. First the group approached “Col de la Madeleine” 1993 m high with a long climb of 26 km. After refreshments, a long descent followed to la Chambre. Then, crossing over to the other side of the valley the ascent to the “Col du Glandon” began. One of the hardest passes in the Alps at 1483 m in only 22 km, there is a very steep last 3 km to the top. The scenery was great, the best part of the trip until now. A steep descent brought the riders down to Bourg d´Oisans.

Some of the hardier cyclists included the alp Huez, another 1860 m ascent with a difficult beginning. For them, it was a 150 km day with a total ascent of 4500 m. A really “great day” for the group!

Tour de Coeur fourth day

After yesterday’s energy-sapping leg we would welcome a flat route like last year in Holland. But already, the Col d’Ornon rises like a giant wall in front of us. It’s raining, and after the first ascent at a temperature of only 9°C we start the descent.

Now the profile of the route resembles a malaria fever chart: up and down, on and on.

But while it’s still raining and we are soaking wet, we get glimpses of the magnificent landscape, the craggy mountains, the deep ravines, the beautiful high valleys with their peaceful pine forests. And finally, we reach the day’s goal, our hotel in Gap. Exhausted but happy after 110 km and 2050 meters of altitude climbing we rest, dry our clothes and order an extra-large portion of pasta!

Our Facebook pages: https://www.facebook.com/schweizerischeherzstiftung (German)

https://www.facebook.com/FondationSuisseDeCardiologie (French)

Website: http://www.tourdecoeur.ch

Tour de Coeur fourth day, Philipp Haager reports

Sunshine! After a day like yesterday, this word is wonderful.

We start with great alpine scenery, leaving Gap heading southwest down to the river Durance following Napoleon’s route. A powerful south wind made it hard to cycle. Slipstream was the magic word of the day.

We left the valley to the west and went uphill again through the wonderful and wild Canyon of Méouge. At the pass “Col de Macuégne”, we first saw the “Mont Ventoux”. The magic mountain that will be the highlight of the next day. We finished in Sault after 111 km and 1198 m total ascent.

Tour de Coeur Day 5, Philipp Haager reports

A wonderful morning in the Provence: blue sky, warm and a smooth ascent up to the foothills of Mont Ventoux (1912m). We pass fields of lavender with its fantastic smell before entering into the pinewood forest. This is a capitol for biking: from every side come bikers and cyclists up to the top, like pearls on a pearl necklace!

A strong wind but also an incredible view of the Mediterranean Sea to the south and up to the Massif des Écrins with its snow covered peaks to the north!

Going downhill was a great run especially to enter the South of France summer. A wonderful 34° C awaited us after 99 km and a total climb of 1530m in Avignon.

Tour de Coeur Day 6, Philipp Haager reports

After yesterday’s gorgeous day (day 5), we had to start early, to catch the TGV to Spain. We then hit the road again in Figueres. Of course, it started with a short shower of warm summer rain, but the temperature at 21o C was much more comfortable compared with Col de Ornon 3 days ago.

Small streets behind the coastline and a wonderful downhill sloping trail through olive groves, guided us to Peratallada.

We finished the day bathing in the sea after 82 km.

Tour de Coeur ends

After a week in the saddle, the team of 35 cycling Swiss cardiologists arrived on time in front of the Fira Gran Via on Saturday 30 August. Their 760 kilometre route from Geneva had crossed the famous Alpine passes of the Tour de France, all in aid of the Swiss Cardiology Foundation.

‘Fantastic,’ said Professor Hans Rickli. ‘Better to exercise than to talk about it.’

European Heart Journal Supplement: The Heart of the Matter

Cardiology is in constant evolution and the European Heart Journal Supplement (EHJs) has also changed.

Together with a group of excellent Associate Editors (Francisco Fernández-Aviles, Jeroen Bax, Michael Böhm, Frank Ruschitzka and Thomas Lüscher) an entirely new product has been developed the EHJs – the Heart of the Matter. The Editor-in-Chief is Prof Roberto Ferrari, Ferrara, Italy.

The EHJs – the Heart of the Matter intends to offer a service, not only to the usual sponsors but also to the ESC family, providing a dedicated, scientific space for the Affiliate Societies and, if needed, the National Societies, Associations, Working Groups and Councils the opportunity to disseminate their important successes to all of the 28,000 worldwide subscribers at a substantially reduced cost.

No matter how innovative a scientific journal is, its Impact Factor provides a numeric measure of its scientific value and success. The editorial staff are proud to report that the EHJs – the Heart of the Matter currently has an Impact Factor of 5.6 which is one of the highest for a similar journal.

Further information is available through the ESC Journals webpage: http://www.escardio.org/journals

The "Ten Commandments" of the ESC Guidelines 2014

Guidelines on Non-Cardiac Surgery: Cardiovascular Assessment & Management; by Steen D Kristensen MD and Juhani Knuuti MD

1. A multidisciplinary expert team should be consulted for preoperative evaluation of patients with known or high risk of cardiac disease undergoing high-risk non-cardiac surgery.

2. The surgical risk assessment - which depends on the planned procedure - has been completely updated. Further, when alternative methods to the classical open surgery are considered - either through endovascular or less invasive endoscopic procedures - the potential trade-offs between early benefits due to reduced morbidity and mid-long term efficacy must be considered. Accordingly, the GL recommends that patients should undergo preoperative risk assessment independently of an open or laparoscopic surgical approach.

3. The patient risk assessment now includes not only the Lee score but also other validated risk scores such as NSQIP. The new version also has recommendations about the role of biomarkers (BNP and Troponins) for risk assessment.

4. The risk reduction section has also been completely updated. The key change is that preoperative initiation of beta-blockers is not recommended in all patients but may be considered in patients scheduled for high-risk surgery and who have clinical risk factors, or who have known ischaemic heart disease or myocardial ischaemia. When initiated, the dose should be titrated. If the patient has already had beta-blocker therapy before surgery, continuation is recommended.

5. The recommendation of the use of aspirin and P2Y12 inhibitors for patients undergoing non-cardiac surgery has been updated. New oral anticoagulants are now available and recommendations on how to manage patients treated with these drugs undergoing non-cardiac surgery is described in a new section.

6. The recommendations for the timing of non-cardiac surgery in cardiac-stable/asymptomatic patients with previous revascularization has also been updated by considering new information on safety margins after various revascularization procedures. As in previous GL, routine prophylactic myocardial revascularization before low- and intermediate-risk surgery in patients with proven IHD is not recommended but may be considered before high-risk surgery, depending on the extent of a stress-induced ischaemia.

7. The entire section on specific diseases has been completely updated and several new sections have been added. The section now covers numerous conditions that will influence preoperative evaluation, i.e. chronic heart failure, arterial hypertension, valvular heart disease, arrhythmias, renal disease, carotid disease, peripheral artery disease, pulmonary artery hypertension and pulmonary disease as well as congenital heart disease.

8. The perioperative monitoring section has also been updated and expanded by the anaesthesia experts from European Society of Anaesthesiology. This section now includes parts on intra-operative anaesthetic management, neuraxial techniques, peri-operative goal-directed therapy, risk stratification after surgery, early diagnosis of post-operative complications and postoperative pain management, as well as specific recommendations about the anaesthesia.

9. Naturally, these numerous changes also led to major revisions of the summary table and step-by-step guidance sections at the end of the document. However, this section was considered very useful for users and these revisions were successfully managed. The recommendations for the step-by-step approach as well as one comprehensive table summarizing most of the recommendations are included in the guideline document as well is in the pocket guideline.

10. Randomized clinical trials on the perioperative use of beta-blockers and other drugs are highly needed.

Guidelines on Diagnosis & Management of Hypertrophic Cardiomyopathy; by Perry Elliott MD

1. Clinicians should consider referral of patients to multidisciplinary teams with expertise in the diagnosis, genetics, risk stratification and management of heart muscle disease.

2. A clinically focused approach to the diagnosis of genetic and acquired causes of HCM based on careful history including analysis of family pedigrees and a cardiomyopathy-centred interpretation of commonly used diagnostic tools such as electrocardiography and cardiac imaging should be adopted.

3. Genetic counselling is recommended in all patients with unequivocal HCM when it cannot be explained solely by a non-genetic cause

4. When a definite causative genetic mutation is identified in a patient, his or her first degree relatives should first be genetically tested, and then clinically evaluated if they are found to carry the same mutation.

5. Exercise stress echocardiography is recommended in symptomatic patients with LVOT gradient <50 mmHg at rest.

6. When a gradient is detected in the left ventricle cavity, obstruction caused by sub-aortic membranes, structural mitral valve leaflet abnormalities and mid-cavity obstruction should be systematically excluded.

7. Use of a new risk calculator (HCMRisk-SCD) is recommended to guide the use of implantable cardioverter defibrillators (ICD).

8. Patients with HCM and paroxysmal, persistent or permanent atrial fibrillation should receive treatment with vitamin K antagonists and lifelong therapy with oral anticoagulants is recommended, even when sinus rhythm is restored.

9. Patients in sinus rhythm with left atrium diameter ≥45 mm should undergo 6–12 monthly 48-hour ambulatory ECG monitoring to detect AF.

10. Most women with HCM tolerate pregnancy well but require expert advice before conception and throughout pregnancy.

Guidelines on Myocardial Revascularization; by Pieter Kappete

1. Revascularization through CABG or PCI is recommended for patients with angina symptoms despite optimal medical therapy, patients who prefer PCI to medical therapy and for those with lesions with a proven survival benefit.

2. CABG is recommended in patient with a primary indication of aortic or mitral valve surgery and coronary artery diameter stenosis of more than 70%.

3. Risk stratification and scores: STS score, Euroscore II and Syntax II factor into assessing patients undergoing revascularization. But clinical judgment and a heart team decision in complex cases is mandatory. Patients should be adequately informed of short-term risk and long-term benefits of revascularization procedures.

4. FFR during diagnostic angiography often changes management decision; nearly 50% of coronary artery stenoses in the intermediate range are functionally misclassified.

5. Due to long-term survival benefit CABG is preferred in cases of complex CAD.

6. Patients with proximal LAD disease in whom revascularization is recommended can be revascularized with PCI. The CABG option should be offered and the exchange of higher early morbidity vs a lower rate of repeat revascularization should be discussed.

7. Multiple arterial grafts are recommended for younger patients undergoing revascularization with CABG.

8. Optimal medical treatment should accompany revascularization with focus on risk factor reduction

9. Graft flow measurement may be useful in patients with hemodynamic instability or inability to wean from extracorporeal circulation.

10. Off pump surgery does not seem to improve short or long-term outcome for most patients and is associated with inferior early and late graft patency rates.

Guidelines on Aortic Diseases; by Raimund Erbel MD

1. First guideline on diseases of the thoracic and abdominal aorta as one organ including not only acute aortic syndromes, but also aortic aneurysms, genetic and congenital diseases, aortic inflammation and aortic tumours.

2. Modern imaging of the aorta permits visualization of the total aorta requiring standardized reports and measurements at given landmarks.

3. A two-minute added scan of the abdominal aorta, should be used in all elderly patients undergoing transthoracic echocardiography to effectively screen for abdominal aortic aneurysms (AAA).

4. A comprehensive list of standard values is given for all imaging techniques.

5. A flow chart for the Emergency Room is designed to enhance efficacy of decision-making in acute aortic syndromes - survival is highly time-dependent.

6. Diagnostic steps and therapeutic options are described not only for aortic dissection, but also for intramural haematoma, penetrating aortic ulcer, and traumatic aortic injury.

7. The progress of interventional and vascular surgery required detailed discussion of AAA management to find the optimal time window for treatment and selection of endovascular or open surgery.

8. Hybrid Rooms have paved the way for developing new diagnostic and treatment options such as thoracic endovascular aortic repair [(T) EVAR], debranching aortic arch surgery, and the “frozen elephant trunk” technique.

9. New information on genetic and congenital aortic diseases with detailed recommendations, particularly for genetic testing.

10. We should now set up Aortic Teams and Centres to provide full access to specialists in cardiology, radiology, paediatric cardiology, genetics, aortic and vascular surgery, which are required not only for the acute but also for the intensive follow-up of patients with aortic diseases.

Guidelines on Acute Pulmonary Embolism. What is new? What has changed? by Stavros Konstantinides MD and Adam Torbicki MD

1. Assessment of hemodynamic stability of the patient and clinical probability of pulmonary embolism (PE) is the basis of all diagnostic strategies.

2. Appropriate use of D-dimer testing may reduce the need for unnecessary imaging and irradiation.

3. While computed tomographic (CT) angiography plays a key role in diagnostic algorithms, ventilation-perfusion (V/Q), compression venous ultrasonography (CUS) and emergency echocardiography may be helpful in management decisions.

4. Clinical assessment may identify patients at high risk (with shock or hypotension) requiring primary revascularization therapy, and patients at low risk of early death despite confirmed PE (PESI* classes I or II) who can be considered for early discharge if appropriately anticoagulated.

5. Among the remaining patients, those with signs of both right ventricular overload and positive humoral biomarkers (troponin, BNP) represent an intermediate-high risk group which should be monitored, as they may require rescue reperfusion therapy if clinical signs of haemodynamic decompensation appear.

6. Primary reperfusion treatment, particularly systemic thrombolysis, is the treatment of choice for patients with high-risk PE.

7. Surgical pulmonary embolectomy or percutaneous catheter-directed treatment are alternative methods of primary and rescue reperfusion treatment.

8. For most cases of acute PE without haemodynamic compromise, low molecular weight heparin (LMWH) or fondaparinux is the initial treatment of choice. Unfractionated heparin (UFH) should be used in hemodynamically unstable patients and those with severe renal dysfunction.

9. The non-vitamin-K-dependent oral anticoagulants (NOACs; direct inhibitors of factor Xa or thrombin) are non-inferior in terms of efficacy and possibly safer, particularly in terms of major bleeding, than the standard anticoagulation regimen consisting of heparin followed by a vitamin K antagonist (VKA).

10. Management of PE in patients with cancer and in pregnancy, duration of anticoagulation after initial episode, and management of patients with persisting symptoms and suspected/confirmed chronic thromboembolic pulmonary hypertension after PE, all require specific considerations and may need to follow separate recommendations – see guidelines.

*PESI = Pulmonary Embolism Severity Index

For more information see:

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