ESC 2024 Congress Conference Highlights (PDF)

ESC Congress 2024 London 30th August – 2nd September CONFERENCE HIGHLIGHTS From the makers of TM TM TM Contents 2024 ESC Guidelines for the Management of Elevated Blood Pressure 1 and Hypertension...3 2024 ESC Guidelines for t...

ESC Congress 2024 London 30th August – 2nd September CONFERENCE HIGHLIGHTS From the makers of TM TM TM Contents 2024 ESC Guidelines for the Management of Elevated Blood Pressure 1 and Hypertension...3 2024 ESC Guidelines for the Management of Chronic Coronary 2 Syndromes...7 3 2024 ESC Guidelines for the Management of Atrial Fibrillation...10 Personalised hypertension management - How to personalise drug 4 treatment in hypertension management?...14 Targeting lipids above and beyond statins: Targeting triglycerides - 5 is it worth it? lessons from recent trials...16 How to personalise lipid-lowering therapy with so many choices – 6 Role of Biomarkers...18 Personalised dual antiplatelet therapy (DAPT) after acute coronary 7 syndromes: De-escalation vs. early cessation of DAPT for patients at high bleeding risk...21 8 Novel drug therapies in hypertension: new kids on the block...24 Possible shifts in paradigms for lipid-lowering therapies in acute 9 coronary syndrome patients: combination therapy from Day 1...26 TM TM TM 2 12 ESC Guidelines 11. Patient-centred care in hypertension 2024 ESC Guidelines for the Management of Elevated Blood Pressure 1 An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended as part of hypertension I C management. and Hypertension Motivational interviewing should be considered for patients with hypertension at hospitals and community health centres to assist patients IIa B in controlling their BP and to enhance treatment adherence. Physician–patient web communications are an effective tool that should be considered in primary care, including reporting on home BP IIa C The 2024 ESC/ESH Guidelines on managing elevated readings. What is the need to update hypertension guidelines? blood pressure andforhypertension update the self-monitored 2018 Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae178/7741010 by guest on 30 August 2024 Home BP measurement managing hypertension by using BP is recommended to achieve better BP control. I B guidelines with several Self-measurement, key changes when properly performed, based on current is recommended due to positive New on v effects clinical evidence the acceptance of a diagnosis of hypertension, I C evidence. The title and patient empowerment, now reflects adherence the continuous risk to treatment. v Address previous gaps ofEnhanced cardiovascular disease self-monitoring (CVD) of BP using associated a device paired with with blood smartphone a connected application may beclinical v Hypertension considered, though trials - A newevidence erato date IIb B © ESC 2024 suggests that this may be no more effective than pressure levels, introducing a new category, “Elevated standard self-monitoring. v Relook at controversies, eg. definition, thresholds, targets Multidisciplinary approaches in the management of patients with elevated BP and hypertension, including appropriate and safe task-shifting BP,” defined as systolic BP of 120–139 mmHg or diastolic away from physicians are recommended to improve BP control. v Translating new knowledge into clinical practicceI A BP of 70–89 mmHg. The guidelines recommend a target systolicblood ABPM, ambulatory BP pressure of 120–129 mmHg monitoring; for adults on enzyme; ACE, angiotensin-converting BP- ACR, Guidelines may valbumin-to-creatinine lose AF, ratio (urine); their atrial clinical fibrillation; relevance ALARA, as lowas they age as reasonably and achievable; lowering medications, with personalized adjustments newer ARB, angiotensin receptor blocker; BP, blood pressure; CAC, coronary artery calcium; CCB, calcium research channel blocker;emerges CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HBPM, home blood pressure monitoring; HFpEF, heart failure with preserved ejection fraction; HIV, human immunodeficiency virus; HMOD, for specific populations. hypertension-mediated A MRA, organ damage; significant shift focuses mineralocorticoid on receptor antagonist; RAS, renin–angiotensin system; SCORE2, Systematic COronary Risk Evaluation 2; SCORE2-OP, Systematic COronary Risk Evaluation 2–Older Persons; SGLT2, sodium–glucose co-transporter 2. CVD a outcomes rather than just BP reduction, requiring Class I recommendations for interventions to demonstrate CVD benefit. Class of recommendation. The b Leveldocument of evidence. also integrates sex and gender considerations throughout and emphasizes user-friendliness, incorporating input from general practitioners and patients. The Key changes in 2024 guideline includes. Table 4 Revised recommendations Recommendations in 2018 version Classa Levelb Recommendations in 2024 version Classa Levelb 6. Definition and classification of elevated blood pressure and hypertension It is recommended that BP be classified as optimal, It is recommended that BP be categorized as normal, high–normal, or grades 1–3 hypertension, I C non-elevated BP, elevated BP, and hypertension to aid I B according to office BP. treatment decisions. CV risk assessment with the SCORE system is SCORE2 is recommended for assessing 10-year risk of recommended for hypertensive patients who are not fatal and non-fatal CVD among individuals aged 40–69 already at high or very high risk due to established CVD, years with elevated BP who are not already considered I B renal disease, or diabetes, a markedly elevated single at increased risk due to moderate or severe CKD, risk factor (e.g. cholesterol), or hypertensive LVH. established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia. I B SCORE2-OP is recommended for assessing the 10-year risk of fatal and non-fatal CVD among individuals aged ≥70 years with elevated BP who are I B not already considered at increased risk due to moderate or severe CKD, established CVD, HMOD, diabetes mellitus, or familial hypercholesterolaemia. 7. Diagnosing hypertension and investigating underlying causes It is recommended that the diagnosis of hypertension Where screening office BP is 140–159/90–99 mmHg, it is should be based on: recommended that the diagnosis of hypertension should Repeated office BP measurements on more than one be based on out-of-office BP measurement with ABPM I B visit, except when hypertension is severe (e.g. grade 3 and/or HBPM. If these measurements are not logistically and especially in high-risk patients). At each visit, three or economically feasible, then diagnosis can be made on BP measurements should be recorded, 1–2 min apart, repeated office BP measurements on more than one visit. and additional measurements should be performed if I C Where screening office BP is ≥160/100 mmHg: the first two readings differ by >10 mmHg. The It is recommended that BP 160–179/100–109 mmHg patient’s BP is the average of the last two BP readings. be confirmed as soon as possible (e.g. within 1 Or month) preferably by either home or ambulatory BP I C Out-of-office BP measurement with ABPM and/or measurements. HBPM, provided that these measurements are It is recommended when BP ≥180/110 mmHg that logistically and economically feasible. hypertensive emergency be excluded. Continued TM TM TM 3  Echocardiography may be considered when the Echocardiography may be considered in patients with detection ESC A ofBPLVH Guidelines diastolic mayofinfluence target 12 – De-escalation of DAPT intensity (at high ischaemic risk versus high – Followed by SAPT with aspirin months 1-4 weeks) bleeding risk (at 3-6 months) Or Or –Abbreviation of DAPT – Followed by SAPT with P2Y12 followed by P2Y12 inhibitor (at 1-3 inhibitor (at 1-3 months) months) TM TM TM 22 KEY HIGHLIGHTS Personalize the duration and intensity of DAPT for high bleeding risk (HBR) patients based on individual ischemic and bleeding risk profiles. Use tools like PRECISE-DAPT and ARC-HBR scores for bleeding risk stratification and the DAPT score for assessing recurrent ischemic event risk. For HBR patients, consider de-escalating DAPT after one month, stopping aspirin after three months (Class IIa ESC), or discontinuing the P2Y12 inhibitor after six months (Class IIb ESC). TM TM TM 23  8 Novel drug therapies in hypertension: new kids on the block The need for novel therapeutic approaches in hypertension management has become increasingly apparent due to issues such as poor patient adherence, unwanted side effects, and the economic burden of long-term antihypertensive treatments. Traditional methods often fall short in providing sustained blood pressure control, leading researchers to explore alternative options like vaccines. Vaccines for hypertension aim to induce a safe and effective immune response that can offer long-term protection against high blood pressure. The renin-angiotensin system (RAS), a key regulator of blood pressure, has been identified as a suitable target for such vaccines. Although previous attempts to develop RAS-targeting vaccines were unsuccessful due to ineffective BP-lowering, side effects, or inadequate immunological responses, there is renewed hope with advancements in vaccinology. The use of RNA/DNA vaccine technology, which gained prominence during the COVID-19 pandemic, is being explored as a potential game-changer in the fight against hypertension. DAPT strategies in patients with ACS undergoing PCI TM TM TM 24  modification of nucleic acids and encapsulating mRNA in 19 era, the novel vaccine technology d lipid nanoparticles. These companies rapidly, within half a inate among preventive vaccines for inf year, presented initial results of clinical trials to support therapeutic vaccines for chronic diseas their RNA vaccine concept [6, 7], and in a phase 3 clinical Therapeutic trial,vaccine the RNA for hypertension vaccine was found to after be 95% the COVID-19 effective in Era Mechanism of therapeutic va Established Technology Gene Therapy Technology self-antigens Virus vaccine Viral vector For many years, we have aimed at de Live virus vaccines for chronic diseases, such a Adenovirus vector vaccine inactivated virus described above for SARS-CoV-2 vac induced by vaccines usually mimic th Suitable for Activation of against pathogens and stimulate cell Antibody Production Cellular Immunity antibody production through coactivat nity and antigen presentation by anti Protein-based vaccine Nucleic Acid (APCs). In most cases, the therapeuti Recombinant protein RNA vaccine chronic diseases is a self-antigen (i.e., a DNA vaccine Peptide with adjuvant with drug delivery system and not a pathogen or virus. Therefore, developed therapeutic vaccine system gens, which is somewhat different from Fig. 1 Four different types of vaccines. SARS-CoV-2 vaccines have approaches for infectious diseases been actively developed worldwide and are classified into four dif- ferent types of vaccines (virus-based vaccine, protein-based vaccine, First, humans possess an immune viral vector-based vaccine, and nucleic acid-based vaccine). Virus- prevent autoimmune reactions to sel KEY HIGHLIGHTS based vaccines include inactivated and attenuated viruses, which are system can be disrupted to provoke common vectors for preventive vaccines for infectious diseases. antibodies specific against self-ant Protein-based vaccines include recombinant proteins, an outer shell Innovative approaches, such viruses, that mimics as vaccines for long-term such as virus-like particles (VLPs),blood pressuremechanism or peptides, management, aretolerance is T c of immune which are usually suitable for inducing antibody production. This includes central and peripheral tolera needed to address poor adherence, vaccine type may require sidecoadministration effects, andofeconomic burdens of adjuvants to stimulate antihypertensive tolerance system. Central tolerance is treatments. innate immunity, leading to an efficient adaptive immune response. selection”, whereby T cells recognizin Viral vector- (i.e., adenoviral vector) and nucleic acid-based vaccines Immunotherapy targeting (i.e., RNAtheand DNArenin-angiotensin system vaccines) utilize gene therapy (RAS)RNA technology. showsplayed promise, despite by major histocompatibility vaccines and adenoviral vector vaccines have been rapidly approved (MHCs) are removed during their deve previous challenges with vaccine effectiveness and immune response.mus. After central tolerance, peripheral worldwide Advances in RNA and DNA vaccine technology offer potential for developing safer and more effective hypertension treatments, leading to improved patient care. TM TM TM 25  aded j/article/44/38/3720/7243210 859–864 Lifestyle management considered. 13.3.7. Proton pump inhibitors It is recommended Pharmacological that ACS patients adopt a healthy treatment from https://academic.oup.com/eurheartj/article/44/38/3720/7243210 13.3.8.pump Proton Vaccination inhibitors (PPIs) reduce the risk of upper gastroduodenal lifestyle, including: An annualininfluenza 287,836,837 Lipid-lowering therapy bleeding patients vaccination treated withinantiplatelet patients with stable agents. ASCVDTherapy appears stopping all smoking of tobacco to beaassociated with PPI is indicated with for reduced patients incidence receiving ofanyMI,antithrombotic an improved prognosis It is recommended that high-dose statin therapy is regimen 9 Possible shifts in paradigms for lipid-lowering therapies in acute healthy diet (Mediterranean style) ESC who Guidelines in patients are atwith high HF, risk and decreased CV bleeding of gastrointestinal risk in adults (for aged details65see years and Section initiated or continued as early as possible, regardless I 3787 A alcohol restriction I B older.843,844 8.2.2.3, BleedingIn addition, influenza vaccination risk assessment, in the Supplementary given earlydata afteronline). an MI or of initial LDL-C values.787,865–867 in high-risk PPIs that coronary syndrome patients: combination therapy from Day 1 CAD inhibithas 702,703,832,833 been shown CYP2C19, to resultomeprazole particularly in a lower risk and of regular aerobic physical activity and resistance all-cause esomepra- It isexercise recommended to aim to achieve an LDL-C level diabetes. death zole, and CV may deaththe reduce atIn12 the EMMY (EMpagliflozin months. pharmacodynamic 845–847 Therefore, responsein patients influenza to clopidogrel, 13.3.10. withvaccin- acute Hormone replacement therapy I of