At every European Society of Cardiology annual conference, we learn about updated guidelines for a handful of different conditions. Typically these guidelines get modified every 4 or 5 years, and is very important, because new medical evidence appears all the time. To understand any medical guideline, it is important to remember a few key principles. The first, is the level of evidence upon which a guideline recommendation is made. For example, multiple randomised controlled trials are a far higher level of evidence than expert opinion. This is much easier for conditions like raised cholesterol or heart attacks than, for example, niche procedures for rare heart conditions. The second principle is how strong a recommendation is. In lay terms, doctors get advised one of four things: definitely do this for your patients, probably do it, possibly do it, or don’t do it.
Let me give you some examples from this year’s conference. The ESC gave Cardiologists an update on the previous 2019 guidelines on lipids, essentially cholesterol management, with a focus on primary prevention. Regular readers will know I am a huge advocate of primary prevention – or managing a person before they become a patient.
If you saw my video from the conference itself, you will know I had a finger-prick blood test that was offered at one of the stands there. Somewhat concerningly, it suggested my diabetes reading, although still normal, was much closer to pre-diabetic than I would like. In addition, my cholesterol was far higher than when I last had it checked in January. This week I therefore went to get a proper lab sample at my hospital, and was pleased to see the numbers were great – total cholesterol 3.8, LDL 1.8, Triglycerides 0.7, with plum normal diabetes tests. This makes me worry about the accuracy of the finger prick tests, and how many people would be falsely re-assured or worried.
Do you know your numbers?
The latest update on the guidelines reinforce the role of imaging in assessment of risk, with a high level of recommendation. I have been saying this, and practising it, for years. By imaging, I’m talking predominantly on CT scanning. The authors did point out however that medical economics preclude this being widely adopted at the moment, but at least it is being recommended. Personally I think this is an area ripe for AI, which could bring down the cost considerably, but we are a few years away from this being routine.
They also agree on cut off values for risk of Lipoprotein (a). I have written about this before, and there is information on my members site.
They include a medication called Bempedoic acid with the highest level of recommendation for treating cholesterol, and I find this particularly useful in patients unable to take statins.
A new risk scoring system was introduced to estimate the risk of fatal and non-fatal cardiovascular disease over a 10 year period. This is a similar premise to scores used already, and I must say I don’t like them. They may be ok at evaluating population risk, but are not crystal balls that help with a person in front of me in clinic. Many patients who have had heart attacks would not actually be deemed at high risk using the scoring system typically in use in the UK, which rather makes my point for me.
One thing I did really like was the mention of risk modifiers – things that doctors and patients should watch out for that whilst might not be a conventional risk for a heart attack like smoking, still should be carefully assessed and managed to bring down overall risk: sleep apnoea, auto-immune disease, pre-eclampsia, premature menopause, Lipoprotein (a), HIV, obesity, physical inactivity, family history, stress, social deprivation, persistently raised inflammatory markers in the blood and polycystic ovaries.
I mentioned at the top that guidelines also tell us what not to do. Interestingly, this latest update recommends againstusing supplements or vitamins to reduce cardiovascular risk, as their benefits were considered insufficient. This is an area I get asked about quite a lot, so useful to see this in writing.
However one of my biggest take aways, and if you remember nothing else, is that HDL is no longer considered a protective factor in the latest guidelines. This has to be up in the top 3 misconceptions in heart disease in my view. It’s something patients ask me about every week, and in fact, I’ll do my video on it.
I don’t like a show-off, but I must admit it is nice to have things I’ve been banging on about for years in the latest cardiology guidelines!