Dr Mirvat Alasnag

"Hello, everyone. I'm Mirvat Alasnag. I'm an ESC Programme Committee member and an interventional cardiologist in Saudi Arabia. With me here is Dr Khaled Al-Shaibi, interventional cardiologist and head of the cardiac centre in the military hospital in Saudi Arabia. And this is day one of the ESC Congress and a lot of new information was presented today, including the guidelines, which I want to dive right into. Dr Al-Shabi, the acute coronary syndrome guidelines were presented earlier today. So you want to tell us a quick summary on what were the most relevant recommendations that came out of those guidelines today?

Dr Khaled Al-Shaibi

Well, yeah, as you said, the ACS guidelines for 2023 were announced this morning and they are essentially an update on a combination of the 2017 STEMI guidelines and the 2020 NSTEMI guidelines. They've been put into one guideline for ACS. Obviously, AC is a spectrum that covers both STEMI and NSTEMI. As far as the pathways for STEMI pathway and the NSTEMI pathway, there were really no significant changes for the STEMI pathway. But in the NSTEMI pathway, there was some significant changes in the recommendation, the prior recommendation for high-risk NSTEMIs, and that is revascularization within the first 24 hours that previously, in the 2020 guidelines had received. A 1A recommendation has been downgraded to a 2A recommendation. The reasons for that were really pinned on a large meta-analysis done of prior studies that was published in 2022 that showed that the early strategy of cathing these patients within the first 24 hours didn't really affect the hard endpoints of mortality and most of the benefit was for recurrent ischemic events. Furthermore, these earlier studies on which that underpinned this recommendation did not include the screening of these patients for high-sensitivity troponins.

Another interesting change in the guidelines was related to the timing or the type of pretreatment we give these patients who present with ACS aspirin remains a class one indication for these patients. But as far as P2Y12 inhibitors, there's been a change. They're no longer recommended a class 1 recommendation as pretreatment, but rather receive a 2B recommendation for STEMI patient and actually a class three indication for NSTEMI patient. Another change, I think, in the guidelines that was interesting was relating to dual antiplatelet therapy in the high bleeding risk patients. And here again, dual antiplatelet recommendation received a two B indication for all patients and a class two A recommendation of abbreviated three to six-month regimen for these types of patients. There were also interesting recommendations regarding imaging and completeness of revascularization that maybe you'd like to expand on.

Dr Mirvat Alasnag

Yeah, so what was very interesting here is that for intracoronary imaging in patients who had an acute coronary syndrome and an identifiable culprit, the use of intracoronary imaging, be it intravascular ultrasound or optical coherence tomography to guide PCI, was afforded a class 2A recommendation. And for those without an identifiable culprit, the recommendation was a two B to use intracoronary imaging with a preference to use OCT. So that was in terms of intracoronary imaging, but then in terms of complete revascularization, one new recommendation actually came and it was for those who present with an acute STEMI and cardiogenic shock. A 2A recommendation for staging the non-infarct related vessel for these patients who have shock while the prior 2A recommendation in terms of doing the revascularization during the index piece admission or procedure and up to 45 days in a standard STEMI was class 1 recommendation. But what was very interesting in this guidelines, or this section of the guidelines, was that angiography was really the basis for evaluating these patients who have multivessel disease that are presenting with acute coronary acute setting, in the acute setting. And so this was a Class 1B recommendation there to use angio guidance only.

But I really want to move on to another set of guidelines that were actually very interesting and were presented today as well, was the Endocarditis guidelines. Now, it included 34 new recommendations, but really a few of them are ones that we ought to highlight for our viewers. The first is it was patient-centered, so they did focus on educating the patients, making sure they're aware of oral hygiene, dental hygiene, tattoos, and so on. But we've all noticed as clinicians an uptick of endocarditis in the past few years, and I'm glad that the new guidelines did address them in terms of prophylaxis. But another interesting aspect that came out of the Endocarditis guidelines is they did add the use of imaging aside from echo such as PET and CT for the evaluation of these patients. And it was afforded the class 2A recommendation. Now, I know you and I had discussions earlier today about the Endocarditis guidelines and there were other issues, other recommendations that are perhaps practice-changing. So what are your thoughts on those?

Dr Khaled Al-Shaibi

Yeah, well, as you know, this guideline is an update. I think the last Endocarditis guidelines were, if I'm not mistaken, 2015 or 2017. So it's been quite a while since these guidelines were updated. And there was an important segment here, I think, on outpatient antibiotic therapy here, which actually received a 2A recommendation. Now, for patients with uncomplicated infective endocarditis, however, obviously, higher-risk patients, those with resistant organisms, those that have complicated endocarditis with abscess formation or post-surgical complicated cases, continue to require in-hospital intravenous antibiotics as prior recommendations. Another one was relating to surgical intervention in these patients. And there were two new class 1 recommendations made in these types of patients. And one of these was 1A recommendation related to valve replacement when treating patients with early prosthetic valve endocarditis, early being within the first six months. So it's a Class 1 indication to replace those valves and perform a thorough surgical debridement. The other new Class 1 recommendation for surgical intervention was for those patients who suffer an embolic stroke an ischemic stroke. And in those in whom the overall neurological prognosis is good for meaningful recovery, they should not be denied surgery. And it's a class 1 indication to operate on these patients.


Dr Mirvat Alasnag

So the other guidelines that also came out were the diabetes guidelines, a lot about the new agents that are now available to us in patients even with and without cardiovascular events. So could you just give us a very brief update on those, Dr. Al-Shaibi?

Dr Khaled Al-Shaibi

Well, yeah, I think, again, as you mentioned, the GLP1 agonists continue to gain strength and momentum in the cardiovascular arena. I think the most relevant notes I made in this guideline section were related to the GLP1 agonist and SGLT2 inhibitors and that generally they could receive. Now class 1 indications for patients with diabetics with all forms of cardiovascular manifestations. Whether we are talking about treating a STEMI patient who's a diabetic, an NSTEMI patient, an unstable angina patient, a chronic coronary syndrome patient, heart failure with preserved EF with moderate LV dysfunction with severe [indistinct]. For all these categories of patients, the presence of diabetes and cardiac disease gives these agents both the GLP1 and the SGLT2 inhibitors as a class 1 indication.

Dr Mirvat Alasnag

And that's irrespective of ejection fraction or diabetes.

Dr Khaled Al-Shaibi

Absolutely. Absolutely. It's a very broad class 1 indication for the use of these agents in all diabetics with cardiovascular disease of any sort. Now, the other second point was screening of diabetics who do not have overt atherosclerotic cardiovascular disease and do not have evidence of end-organ damage. And again, this was a new class one recommendation to screen these patients using a new scoring system, the Score Two Diabetes system, which would divide these patients into low, moderate, high, and very high-risk groups. And obviously, each category receives further recommendations regarding treatment strategies.

Dr Mirvat Alasnag

Correct. And just the next guidelines that did come out were related to heart failure, but brand new were the cardiomyopathy guidelines that actually came out. And there was a lot of emphasis on phenotypic assessment of these patients, genetic assessment of these patients, even when considering ICD implantation. So going beyond an absolute ejection fraction or a number and really doing a lot more testing. Interesting again here is that MRI was upgraded in terms as a recommendation here for these patients. And so patient involvement, a lot of algorithms. It was a very solid guidelines. And to wrap up day one, I think we cannot just stop at the guidelines. It is important that we also talk about some of the trials that were presented here. So, Dr. Al-Shabi, what is one trial presented today in the hotlines that you want to cover?

Dr Khaled Al-Shaibi

Well, again, I'm going to go back to the GLP1 agonists. They just are gaining traction. And the Step heart failure preserved ejection fraction study was very interesting. It tested the hypothesis that patients with obesity, not necessarily diabetes, but obese patients with heart failure and preserved ejection fraction might benefit from weight reduction that can be achieved with GLP1 agonists. So the Step Heart Failure Preserved Ejection fraction trial was a randomized, double-blind, placebo-controlled study that involved 96 sites in 13 countries and included patients with preserved EF and obesity. Preserved EF was an ejection fraction of more than 45% and obesity was defined as a BMI of greater than 30 with heart failure symptoms. The endpoints for the trial there were two endpoints. One was the improvement in symptoms as gauged by the Kansas City Cardiomyopathy Questionnaire and the change in body weight. And in fact, this trial, which used semaglutide compared to placebo and the mean dose of semaglutide was 2.4 milligrams given once a week for the duration of the trial, which was one year, 52 weeks, was positive for both endpoints. There was a significant improvement in quality of life as measured by the Kansas City score. There was a significant reduction in body weight in the semaglutide group compared to the placebo group, and these results were confirmed in the six-minute walk test, which was significantly again improved in the group treated actively with the GLP1 agonists. So I think this was a very important study that's probably going to be reflected in the next set of guidelines which is going to add another indication for GLP1 agonists in patients with heart failure and obesity not necessarily diabetics.

Dr Mirvat Alasnag

And just one last trial that I think we should cover in today's wrap-up is really the COP AF trial. There's been a lot of momentum with colchicine, as you know, in both setting of the acute coronary syndromes and chronic coronary syndromes and so on. In this trial, the COP AF trial, they really looked at the role of colchicine administered 0.5 milligrams at least 4 hours or within 4 hours of the operation. And the endpoint was looking at a reduction in clinically relevant atrial fibrillation and myocardial injury that is non-fatal in these patients who are undergoing thoracic surgery, but it's non-cardiac surgery. They enrolled over 2000 patients, placebo and group and the colchicine group were quite similar actually. It was 3000 patients. It was one-to-one randomization. Close to 48% were women. The mean age was 68 years, but unfortunately did not meet the primary endpoint or the secondary endpoint. So there was really no difference in the rates of both myocardial injury or clinically relevant atrium fibrillation when using colchicine. So that was a wrap-up of today's sessions at Amsterdam and we'll be with you again tomorrow with another wrap-up of the ESC conference.