Predictor of Sudden Death helps identify ICD candidates

New guidelines for patients with hypertrophic cardiomyopathy (HCM) identify candidates for implantable cardioverter defibrillators (ICDs). These devices help protect patients from arrhythmias (an irregular heartbeat) which can limit blood flow to vital organs, like the brain for example. Identifying which pacents would benefit from an ICD has been difficult. But the new guidelines, which were recently published, will help determine the patients most likely to benefit from ICDs by testing to see which of these patients are at higher risk for sudden cardiac death.

Previous ESC Guidelines on hypertrophic cardiomyopathy, which were published in 2003 were long overdue for an update. This latest revision will help doctors better treat patients thanks to the newest advances in medical care, which were not around for the last publication. These new standards will raise the quality of patient care and will end up saving lives and money.

 “One of the most important innovations in this guideline is a new risk calculator that uses simple clinical measures to estimate five year risk of sudden cardiac death. This estimate is then used to stratify patients into high, intermediate and low risk categories that can be used to guide the use of ICDs,” said Task Force Chairperson, Professor Perry Elliott (of the UK).

These recommendations are most likely going to spark considerable interest and debate as they provide advice based on real estimates of risk rather than “relative risks” which were used in all previous guidelines. This will bring into focus the balance between clinical efficacy on the one hand and on the other, the potential risks and the real costs of therapy to individual patients and healthcare economies.

“In some aspects of the guidelines we had to balance an ideal of best practice with the realities of healthcare provision across Europe and elsewhere. Nevertheless, we make a number of recommendations that will prove challenging in some countries with the deliberate aim of raising the general standard of care for all patients,” Dr. Elliott said.

Examples of these changes include a recommendation for genetic testing in all patients with hypertrophic cardiomyopathy (HCM) when it is of relevance to the management of family members; greater use of specialised tests such as cardiac magnetic resonance imaging in everyday practice; and early referral to multidisciplinary teams with expertise in the diagnosis and management of HCM.

This change was made because most cases of HCM have a genetic cause and the guidelines provide a clinically focused approach to the requesting and interpretation of genetic tests. Which is based on careful history taking including analysis of family pedigrees and a cardiomyopathy-centred interpretation of commonly used diagnostic tools such as electrocardiography and cardiac imaging.

“The aim is to improve the accuracy of diagnosis and the management of patients and families with HCM,” said Dr. Eliot, “The role of expert counselling before and after genetic analysis is strongly emphasised and we provide clear guidance on the management of family members in different clinical scenarios based on the results of genetic testing.”

Another large change is that detailed and tailored advice is provided for women with HCM. This includes guidance on pre-pregnancy assessment and the management of labor, and detailed recommendations for contraception, sterilisation and termination. Advice on the diagnosis and treatment of children is also provided for the first time in any addition.

Left ventricular outflow tract obstruction is a common feature of HCM that can be treated with drugs or invasive therapies such as surgery and alcohol septal ablation. For the first time, the guidelines present a systematic approach to the assessment of outflow tract obstruction that can be used to tailor therapies to the characteristics of individual patients. A simple guide is also provided for drug and device therapy in patients with HCM and heart failure.

 “We hope that these guidelines will enable healthcare professionals to raise the standard of care for patients of all ages with HCM by improving the accuracy of diagnosis and the use of a rational, patient centred approach to advice and clinical management,” concluded Dr. Eliot

Some of these changes are striking, others are more common sense, but change is necessary to give patients the best care possible. Changing the guidelines of care seems like a silly thing to be excited about. However, it will allow Doctors to better care for patients and will create an environment that will allow for treating a patient more quickly and with better care.

Now, if only we could get some better health care here in the states…

Sources: 
Perry M. Elliott, (Chairperson) (UK)*, Aris Anastasakis, (Greece), Michael A. Borger, (Germany), Martin Borggrefe, (Germany), Franco Cecchi, (Italy), Philippe Charron, (France), Albert Alain Hagege, (France), Antoine Lafont, (France), Giuseppe Limongelli (2014). 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy
The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC) European Heart Journal : 10.1093/eurheartj/ehu284