Adherence to the European Society of Cardiology/European Society of Anaesthesiology recommendations on preoperative cardiac testing and association with positive results and cardiac events: a cohort study.

BACKGROUND: European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines inform cardiac workup before noncardiac surgery based on an algorithm. Our primary hypotheses were that there would be associations between (i) the groups stratified according to the algorithms and major adverse cardiac events (MACE), and (ii) over- and underuse of cardiac testing and MACE. METHODS: This is a secondary analysis of a multicentre prospective cohort. Major adverse cardiac events were a composite of cardiac death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 30 days. For each cardiac test, pathological findings were defined a priori. We used multivariable logistic regression to measure associations. RESULTS: We registered 359 MACE at 30 days amongst 6976 patients; classification in a higher-risk group using the ESC/ESA algorithm was associated with 30-day MACE; however, discrimination of the ESC/ESA algorithms for 30-day MACE was modest; area under the curve 0.64 (95% confidence interval: 0.61-0.67). After adjustment for sex, age, and ASA physical status, discrimination was 0.72 (0.70-0.75). Overuse or underuse of cardiac tests were not consistently associated with MACE. There was no independent association between test recommendation class and pathological findings (P=0.14 for stress imaging; P=0.35 for transthoracic echocardiography; P=0.52 for coronary angiography). CONCLUSIONS: Discrimination for MACE using the ESC/ESA guidelines algorithms was limited. Overuse or underuse of cardiac tests was not consistently associated with cardiovascular events. The recommendation class of preoperative cardiac tests did not influence their yield. CLINICAL TRIAL REGISTRATION: NCT02573532.

[Chronic coronary syndrome : New classification of stable coronary artery disease]. / Chronisches Koronarsyndrom : Neuklassifikation der stabilen koronaren Herzkrankheit.

In 2019 the European Society for Cardiology (ESC) published guidelines for the diagnosis and management of chronic coronary syndromes (CCS). Thus the term "stable coronary artery disease" is replaced by CCS. The newly introduced term is based on the current understanding of pathogenesis and clinical features of coronary artery disease (CAD) as well as therapeutic management. CCS defines CAD as a chronic process that can be influenced by lifestyle adjustments, pharmacological therapies and invasive interventions (percutaneous coronary intervention, coronary artery bypass grafting) with the aim of stabilization or regression. The present work provides an overview of various scenarios that involve CCS and diagnostic pathways to clarify potentially relevant CAD. It also highlights therapeutic management and secondary preventive procedures in accordance with the current recommendations of the ESC.

The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department.

The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.

Testing cardiovascular autonomic function in the COVID-19 era: lessons from Bologna's Autonomic Unit.

The coronavirus disease 2019 (COVID-19) pandemic has changed the way most medical procedures are performed. Autonomic units, as well as other healthcare sectors, are required to undergo a thorough reorganization of the protocols in order to guarantee the safety of patients and healthcare staff. Cardiovascular autonomic function testing (CAFT) is necessary in certain situations; however, it poses several concerns which need to be addressed. Here, we provide some practical advice based on current national and international health authorities' recommendations and our experience about how to perform CAFT during the COVID-19 emergency. We examine aspects regarding patients, healthcare staff, laboratory preparation, and test performance.

Historical reviews of the assessment of human cardiovascular function: interrogation and understanding of the control of skin blood flow.

Several techniques exist for the determination of skin blood flow that have historically been used in the investigation of thermoregulatory control of skin blood flow, and more recently, in clinical assessments or as an index of global vascular function. Skin blood flow measurement techniques differ in their methodology and their strengths and limitations. To examine the historical development of techniques for assessing skin blood flow by describing the origin, basic principles, and important aspects of each procedure and to provide recommendations for best practise. Venous occlusion plethysmography was one of the earliest techniques to intermittently index a limb's skin blood flow under conditions in which local muscle blood flow does not change. The introduction of laser Doppler flowmetry provided a method that continuously records an index of skin blood flow (red cell flux) (albeit from a relatively small skin area) that requires normalisation due to high site-to-site variability. The subsequent development of laser Doppler and laser speckle imaging techniques allows the mapping of skin blood flow from larger surface areas and the visualisation of capillary filling from the dermal plexus in two dimensions. The use of iontophoresis or intradermal microdialysis in conjunction with laser Doppler methods allows for the local delivery of pharmacological agents to interrogate the local and neural control of skin blood flow. The recent development of optical coherence tomography promises further advances in assessment of the skin circulation via three-dimensional imaging of the skin microvasculature for quantification of vessel diameter and vessel recruitment.

Critical appraisal of international guidelines for the screening and treatment of asymptomatic peripheral artery disease: a systematic review.

BACKGROUND: Peripheral artery disease (PAD) is often asymptomatic but increases the risk of developing cardiovascular events. Due to the uncertainties regarding the quality of related guidelines and a lack of clear-cut evidence, we performed a systematic review and critical appraisal of these guidelines to evaluate their consistency of the recommendations in asymptomatic PAD population. METHODS: Guidelines in English between January 1st, 2000 to December 31th, 2017 were screened in databases including Medline via PubMed, EMBASE, the G-I-N International Guideline Library, the National Guidelines Clearinghouse, the Canadian Medication Association Infobase and the National Library for Health. Those guidelines containing recommendations on screening and treatment for asymptomatic PAD were included, and three reviewers evaluated the quality of the guidelines using Appraisal of Guidelines Research and Evaluation (AGREE) II instrument. Related recommendations were then fully extracted and compared by two reviewers. RESULTS: Fourteen guidelines were included finally and the AGREE scores ranged from 39 to 73%. Most of included guidelines scored low in Rigor of development and Editorial independence, and only two guidelines (ACCF/AHA, AHA/ACC) reached the standard on Conflict of Interest from Institute of Medicine (IOM). Eight guidelines recommended screening at different strength while the others found insufficient evidence or were against screening. Conflicting recommendations on treatment were found in the target value of the lipid lowering and antiplatelet therapy. The treatment policies in three guidelines (BWG, CEVF, ESC) appeared more aggressive, but they had low transparency between guideline developer and industry or did not reach the standard of IOM. CONCLUSIONS: Current guidelines on asymptomatic PAD varied in the methodological quality and fell short of the standard in the rigor of development and editorial independence. Conflicting recommendations were found both on the screening and treatment. More effort is needed to provide clear-cut evidences with high quality and transparency among guideline developer and industry.

Improved accuracy and confidence with multiple-lead recordings from a single-lead mobile electrocardiographic device.

BACKGROUND: Mobile electrocardiograms (mECGs) utilizing smartphone applications are an emerging technology. Typically, a Lead I rhythm strip is recorded. However, interpretation can be difficult in patients with sinus rhythm and low amplitude P-waves (SR-LAP) or atrial flutter (AFL). We hypothesized that patients could independently obtain multi-lead tracings using a commercial mECG device, and that cardiologists who interpreted the multi-lead tracings would make more accurate diagnoses and have more confidence in their interpretation compared to a single lead only. METHODS: Thirty sets of recordings were obtained from 10 patients with either SR-LAP or AFL that was not apparent on Lead I on a standard ECG. Patients recorded Lead I, Lead II, and Lead V1 tracings using AliveCor's KardiaMobile mECG device. Twenty-nine cardiologists reviewed each patient's Lead I tracing, multi-lead tracings (Leads I, II, V1), and 12-lead ECG. Accuracy was noted and each cardiologist rated their level of confidence in their interpretation. RESULTS: All patients were able to record their own single and multi-lead tracings. Single lead, multi-lead, and the 12-lead ECG yielded 36.4%, 84.3%, and 97.7% agreement with the established diagnosis, respectively (P < .01 for each comparison). Overall mean confidence scores (out of a score of 5) were 2.95, 3.50, and 4.47 for single lead, multi-lead, and the 12-lead ECG, respectively (P < .01 for each comparison). CONCLUSIONS: Patients were able to record their own multi-lead mECG tracings. Compared to a single lead recording, multi-lead mECGs significantly improved cardiologists' diagnostic accuracy and confidence in their interpretation approaching that of a standard 12-lead ECG.

Direct Comparison of 2 Rule-Out Strategies for Acute Myocardial Infarction: 2-h Accelerated Diagnostic Protocol vs 2-h Algorithm.

BACKGROUND: We compared 2 high-sensitivity cardiac troponin (hs-cTn)-based 2-h strategies in patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED): the 2-h accelerated diagnostic protocol (2h-ADP) combining hs-cTn, electrocardiogram, and a risk score, and the 2-h algorithm exclusively based on hs-cTn concentrations and their absolute changes. METHODS: Analyses were performed in 2 independent diagnostic cohorts [European Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) study, Australian-New Zealand 2-h Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker (ADAPT) study] employing hs-cTnT (Elecsys) and hs-cTnI (Architect). The final diagnosis was adjudicated by 2 independent cardiologists. RESULTS: AMI was the final diagnosis in 16.5% (95% CI, 14.6%-18.6%) of the 1372 patients in APACE, and 12.6% (95% CI, 10.7%-14.7%) of 1153 patients in ADAPT. The negative predictive value (NPV) and sensitivity for AMI were very high and comparable with both strategies using either hs-cTnT or hs-cTnI in both cohorts (all statistical comparisons nonsignificant). The percentage of patients triaged toward rule-out was significantly lower with the 2h-ADP (36%-43%) vs the 2-h algorithm (55%-68%) with both assays and in both cohorts (P < 0.001). The sensitivity of the 2h-ADP was higher for 30-day major adverse cardiovascular events. CONCLUSIONS: Both algorithms provided very high and comparable safety as quantified by the NPV and sensitivity for AMI and major adverse cardiac events (MACE) at 30 days in patients triaged toward rule-out, although sensitivity for MACE at 30 days was lower with both algorithms in cohort 2. Although the 2-h algorithm was more efficacious, not all patients ruled out for AMI by this algorithm were appropriate candidates for early discharge. The 2h-ADP seems superior in the selection of patients for early discharge from the ED. CLINICAL TRIAL REGISTRATION: APACE: http://clinicaltrials.gov/show/NCT00470587ADAPT: Australia-New Zealand Clinical Trials Registry ACTRN12611001069943.

Insertion of miniaturized cardiac monitors outside the catheter operating room: experience and practical advice.

Minor surgical procedures are increasingly being performed as outpatient procedures in settings outside hospital operating rooms (ORs). In electrophysiology, the recent miniaturization of insertable cardiac monitors (ICMs) has enabled the routine insertion of the device as a minimally invasive procedure without the need of a catheter OR. However, a shift to office-based environments for minor surgical procedures is associated with some concerns, particularly with respect to patient- and procedure-related safety in the new setting. In the present document, the authors provide practical advice on facilities, practices, and adaptations necessary when performing ICM insertions in office settings, based on available recommendations as well as their own experience with the use of the novel Reveal LINQ ICM. The main differences from in-hospital implant settings are simplified requirements of room, equipment, and insertion procedures, while ensuring and maintaining an adequate, sterile environment. Patient selection is important: certain groups of patients are recommended to be treated in the catheter OR (e.g. those at increased risk for bleeding or very frail elderly individuals). Insertion in alternative positions, as is sometimes performed for cosmetic reasons, should be referred to dedicated hospitals. Quality assurance and internal quality control are critical in the new procedural landscape, and it is important not to trivialize minor surgical procedures. Operators' sharing of experiences and lessons learned, e.g. in the form of registries, should be encouraged.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart Failure.

BACKGROUND: Multiorgan ultrasound (US), which includes evaluation of the lungs and heart, is an accurate method that outperforms clinical gestalt for diagnosing acutely decompensated heart failure (ADHF). A known barrier to ultrasound use is the time needed to perform these examinations. OBJECTIVE: The primary goal of this study was to determine the test characteristics of a modified lung and cardiac US (LuCUS) protocol for the accurate diagnosis of ADHF. METHODS: This was a secondary analysis of a prospective observational study that enrolled adult patients presenting to the emergency department with undifferentiated dyspnea. Intervention consisted of a modified LuCUS protocol performed by experienced emergency physician sonographers. A positive modified LuCUS protocol was defined as the presence of B+ lines in both the left and right anterosuperior lung zones, plus a left ventricular ejection fraction <45%. If all three of these findings were not present, the modified LuCUS result was interpreted as negative for ADHF. The primary objective was measured by comparing US findings to final diagnosis independently determined by two physicians, both blinded to US findings and each other's final diagnosis. RESULTS: We analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the modified LuCUS protocol are 25% (95% confidence interval [CI] 14-41%), 100% (95% CI 94-100%), undefined, and 0.75 (95% CI 0.62-0.91%), respectively. This modified protocol takes on average 1 min and 32 sec to complete. CONCLUSION: The point estimate for the specificity of the modified LuCUS protocol in this pilot study, accomplished by a reanalysis of data collected for a previously reported investigation of the full LuCUS protocol, was 100% for the diagnosis of ADHF.

The Diagnostic Accuracy of Clinical Diagnostic Tests for Thoracic Outlet Syndrome.

Clinical Scenario: Thoracic outlet syndrome is quite challenging to diagnose. Currently, there are myriad diagnostic procedures used in the diagnosis of all types of thoracic outlet syndrome. However, controversy exists over which diagnostic procedures produce accurate findings. CLINICAL QUESTION: Can clinical diagnostic tests accurately diagnose patients presenting with symptoms of thoracic outlet syndrome? Summary of Key Findings: A thorough literature search returned 6 possible studies; 3 studies met the inclusion criteria and were included. Two studies supported the use of clinical diagnostic tests for the diagnosis of thoracic outlet syndrome. One study reported high false-positive rates among clinical diagnostic tests for thoracic outlet syndrome. One study reported that clinical diagnostic test findings correlate to provocative positioned magnetic resonance imaging findings. Clinical Bottom Line: There is moderate evidence to support the use of the Halstead maneuver (also known as the costoclavicular maneuver or exaggerated military brace test), Wright's test, Cyriax Release test, and supraclavicular pressure test to have good diagnostic accuracy for the provocation of symptoms in patients presenting with upper extremity pathology. However, these clinical diagnostic tests do not appear to allow for the differential diagnosis of thoracic outlet syndrome exclusively. The use of the Adson's test and Roos test should be discontinued for the differential diagnosis of thoracic outlet syndrome. Strength of Recommendation: Grade B evidence exists to support the accuracy of the Halstead maneuver, Wright's test, Cyriax Release test, and supraclavicular pressure test for the diagnosis of upper extremity pathology in general. Grade C evidence exists for the use of these clinical diagnostic tests to exclusively diagnose thoracic outlet syndrome.

Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.

BACKGROUND: Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances. METHODS AND RESULTS: This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations. CONCLUSIONS: Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.

Calibrated variability of muscle sympathetic nerve activity during graded head-up tilt in humans and its link with noradrenaline data and cardiovascular rhythms.

Muscle sympathetic nerve activity (MSNA) variability is traditionally computed through a low-pass filtering procedure that requires normalization. We proposed a new beat-to-beat MSNA variability computation that preserves dimensionality typical of an integrated neural discharge (i.e., bursts per unit of time). The calibrated MSNA (cMSNA) variability technique is contrasted with the traditional uncalibrated MSNA (ucMSNA) version. The powers of cMSNA and ucMSNA variabilities in the low-frequency (LF, from 0.04 to 0.15 Hz) band were computed with those of the heart period (HP) of systolic and diastolic arterial pressure (SAP and DAP, respectively) in seven healthy subjects (age, 20-28 years; median, 22 years; 5 women) during a graded head-up tilt. Subjects were sequentially tilted at 0°, 20°, 30°, 40°, and 60° table inclinations. The LF powers of ucMSNA and HP variabilities were expressed in normalized units (LFnu), whereas all remaining spectral markers were expressed in absolute units. We found that 1) the LF power of cMSNA variability was positively correlated with tilt angle, whereas the LFnu power of the ucMSNA series was uncorrelated; 2) the LF power of cMSNA variability was correlated with LF powers of SAP and DAP, LFnu power of HP and noradrenaline concentration, whereas the relationship of the LFnu power of ucMSNA variability to LF powers of SAP and DAP was weaker and that to LFnu power of HP was absent; and 3) the stronger relationship of cMSNA variability to SAP and DAP spectral markers compared with the ucMSNA series was confirmed individually. The cMSNA variability appears to be more suitable in describing sympathetic control in humans than traditional ucMSNA variability.

Estimating the Cost-Effectiveness of Implementation: Is Sufficient Evidence Available?

BACKGROUND: Timely implementation of recommended interventions can provide health benefits to patients and cost savings to the health service provider. Effective approaches to increase the implementation of guidance are needed. Since investment in activities that improve implementation competes for funding against other health generating interventions, it should be assessed in term of its costs and benefits. OBJECTIVE: In 2010, the National Institute for Health and Care Excellence released a clinical guideline recommending natriuretic peptide (NP) testing in patients with suspected heart failure. However, its implementation in practice was variable across the National Health Service in England. This study demonstrates the use of multi-period analysis together with diffusion curves to estimate the value of investing in implementation activities to increase uptake of NP testing. METHODS: Diffusion curves were estimated based on historic data to produce predictions of future utilization. The value of an implementation activity (given its expected costs and effectiveness) was estimated. Both a static population and a multi-period analysis were undertaken. RESULTS: The value of implementation interventions encouraging the utilization of NP testing is shown to decrease over time as natural diffusion occurs. Sensitivity analyses indicated that the value of the implementation activity depends on its efficacy and on the population size. CONCLUSIONS: Value of implementation can help inform policy decisions of how to invest in implementation activities even in situations in which data are sparse. Multi-period analysis is essential to accurately quantify the time profile of the value of implementation given the natural diffusion of the intervention and the incidence of the disease.

[ESC and AHA guidelines 2015 on endocarditis : In competition or synchrony?] / ESC/AHA-Endokarditisleitlinien 2015 : Wettstreit oder Gleichklang?

In the 2015 guidelines of the European Society of Cardiology (ESC) and the American Heart Association (AHA) on infective endocarditis, the diagnostics are based on the modified Duke criteria. The diagnosis can be confirmed by a combination of micro-organisms demonstrated in culture or in situ, with the detection of valvular lesions or abscess formation by an imaging modality using echocardiography, positron emission tomography computed tomography (PET/CT), cardio-CT or nuclear medical methods. The management should be further improved by an interdisciplinary endocarditis team in a specifically designated reference center. Pharmaceutical treatment is largely unchanged and based on classical antibiotics in monotherapy or as combination therapy but for staphylococcal endocarditis, gentamycin is no longer required. As cardiac surgery is needed in 50 % of the cases during the course of the disease, the urgency for surgery depends on the extent of cardiac insufficiency, the persistence of the pathogen despite antibiotic treatment and on neurological complications.

[The new ESC Guidelines for acute and chronic heart failure 2016]. / Neuerungen der ESC-Leitlinien zur akuten und chronischen Herzinsuffizienz 2016.

The new guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) were presented in May 2016 during the congress of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) in Florence. An important amendment affects the classification of HF which now differentiates between HF with preserved ejection fraction (HFpEF) and left ventricular EF (LVEF) > 50%, HF with reduced ejection fraction (HFrEF, LVEF < 40%) and the new entity HF with mid-range ejection fraction (HFmrEF, LVEF 40-49%). Additionally, there are revised algorithms for the diagnosis and treatment for acute and chronic HF. The algorithm for the diagnosis of acute HF is based on the clinical presentation and from this prognosis and treatment options can be derived. The algorithm for the diagnosis of chronic HF is now based on the probability for HF in a 3-step model comprised of clinical presentation, patient history and electrocardiogram (ECG) abnormalities, together with increased plasma levels of N­terminal propeptide brain natriuretic peptide (NT-proBNP, normal <125 pg/ml) and BNP (normal <35 pg/ml). Echocardiographic assessment is essential to confirm the diagnosis and obtain further differentiation. Essential updates to medicinal therapy include the introduction of a novel drug class of angiotensin receptor neprilysin inhibitors (ARNI, sacubitril/valsartan) as a class I/B indication in the HFrEF treatment recommendations according to the PARADIGM-HF trial data. Additionally, due to the EMPA-REG trial the sodium-dependent glucose transporter 2 (SGLT2) inhibitor empagliflozin has been recommended in the new guidelines for the prevention of symptomatic HF in high-risk patients (class IIa/B indication). For cardiac resynchronization therapy (CRT) a novel class I/A indication for QRS > 150 ms and left bundle branch block (LBBB), a class I/B indication for QRS > 130 ms and LBBB as well as high-grade atrioventricular block with pacemaker indications have been put forward. The Life Vest® for bridging therapy of high-risk patients received a class IIb/C indication. In this article we summarize the major novelties of the ESC guidelines 2016 and shed light on the underlying innovations and clinical trials.

[ECS guidelines 2016 - dyslipidaemias]. / ESC-Leitlinien 2016 ­ Dyslipidämien.

Dyslipidaemia is a major cause of atherosclerotic cardiovascular disease and its progression towards clinical complications, such as acute coronary syndromes and stroke. In August 2016 the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) issued new joint guidelines for the management of dyslipidaemias. In these new guidelines, the concept of treating patients to a risk-based low-density lipoprotein (LDL) cholesterol target is reinforced. The task force considers LDL cholesterol as the primary target for dyslipidaemia treatment, whereas high-density lipoprotein (HDL) cholesterol is not recommended as a treatment target (based on the failure of HDL cholesterol elevation treatment strategies to reduce cardiovascular risk in recent studies). In patients with a very high risk for cardiovascular events it is recommended to treat to an LDL cholesterol target of less than 70 mg/dl. Moreover, the new guidelines now additionally recommend a > 50% reduction of LDL cholesterol in patients with very high cardiovascular risk patients and baseline levels between 70 and 135 mg/dl as well as in patients with high cardiovascular risk and baseline LDL cholesterol levels between 100 and 200 mg/dl. Statins are recommended as first-line medicinal treatment and the LDL cholesterol goals given imply the more frequent use of maximum tolerated statin therapy, in particular for patients with very high cardiovascular risk. Treatment with ezetimibe in patients with substantially elevated LDL cholesterol levels despite maximum tolerated statin therapy has now received a stronger recommendation (currently IIa recommendation). The guidelines also now include the potential use of the novel proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and a recent ESC/EAS consensus document provides more detailed information on which patients can be considered for treatment with PCSK9 inhibitors, i. e. in particular patients with familial hypercholesterolemia and patients at very high cardiovascular risk who have markedly elevated LDL cholesterol levels despite maximum tolerated statin and ezetimibe therapy.

[Cardiovascular prevention and regular physical exercise : Activity and training as the true "polypill"]. / Kardiovaskuläre Prävention und regelmäßige körperliche Aktivität : Bewegung und Training als wahre "polypill".

Guidelines for cardiovascular prevention need to be regularly revised and updated. With respect to physical activity and exercise, many studies with practical relevance have been published in recent years. They are concerned with the evidence of physical activity for prevention of many diseases and the spectrum of indications for applying physical activity for prevention, therapy and rehabilitation. Training recommendations have been developed for the prevention of various diseases according to the FITT rule, which stands for frequency, intensity, time (of session) and type of sports followed by a progression in the amount of training. Recent publications show that moderate exercise with an increase in regular activity (e.g. 10,000 steps per day) is a sufficient approach for risk reduction in many diseases. An as yet unresolved problem is the best approach for effective motivation for physical exercise. The prescription of exercise is an important approach for improving the motivation for physical activity; however, prescribing exercise needs basic knowledge in sports physiology and proper training recommendations. Furthermore, population-based interventions for physical activity are urgently needed to implement more physical activity in the daily routine. The current ESC guidelines provide a great deal of new information to be implemented in the prevention in primary care; however, with regard to physical activity, more comprehensive biological data of physical activity should be presented in order to improve physician's knowledge, thus enhancing the fight against inactivity and sedentary lifestyles as one of the most significant risk factors.

[ESC guidelines on atrial fibrillation 2016 : Summary of the most relevant recommendations and modifications]. / ESC-Leitlinien zum Vorhofflimmern 2016 : Zusammenfassung der wichtigsten Empfehlungen und Neuerungen.

The first European Society of Cardiology (ESC) guidelines on atrial fibrillation (AF) developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) were published in August 2016. These guidelines replace the revised guidelines from 2012 and contain some interesting new aspects. The topics range from the pathophysiology through diagnostics, therapy and stroke prevention up to special clinical situations, such as atrial fibrillation in cardiopathy, sport and pregnancy. Early screening, patient informed consent, individualized therapy and the modification of factors promoting atrial fibrillation are of particular importance. The guidelines recommend the establishment of AF heart teams, containing specialists from various disciplines. The guidelines also underline the importance of non-vitamin K­dependent oral anticoagulants (NOAC) for stroke prevention compared to standard anticoagulants with vitamin K antagonists. For symptomatic and especially paroxysmal atrial fibrillation, the guidelines emphasize the importance of an antiarrhythmic treatment with catheter ablation and/or pharmaceutical antiarrhythmic therapy in addition to a frequency regulating therapy.