Guidelines and Expert Consensus Documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians select the best possible management strategies for the individual patient suffering from a specific condition, taking into account the impact on outcome and also the risk–benefit ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the minds of physicians. In order to avoid these pitfalls, the ESC and other organizations have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website.1 It is beyond the scope of this preamble to recall all but the basic rules.

In brief, the ESC appoints experts in the field to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the risk–benefit ratio of the therapies recommended for management and/or prevention of a given condition. Estimates of expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed according to predefined scales for grading recommendations and levels of evidence, as outlined in what follows.

The Task Force members of the writing panels, …

Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

Authors/Task Force Members, Alec Vahanian (Chairperson) Paris (France)*, Helmut Baumgartner, Vienna (Austria), Jeroen Bax, Leiden (The Netherlands), Eric Butchart, Cardiff (UK), Robert Dion, Leiden (The Netherlands), Gerasimos Filippatos, Athens (Greece), Frank Flachskampf, Erlangen (Germany), Roger Hall, Norwich (UK), Bernard Iung, Paris (France), Jaroslaw Kasprzak, Lodz (Poland), Patrick Nataf, Paris (France), Pilar Tornos, Barcelona (Spain), Lucia Torracca, Milan (Italy), Arnold Wenink, Leiden (The Netherlands)

Guidelines on the Management of Valvular Heart disease (Version 2012)

Effect of Study Setting on Anticoagulation Control* A Systematic Review and Metaregression

Among the many effects of heparin independent of its effects on coagulation are inhibition of vascular smooth muscle cell proliferation and regulation of leukocyte-blood vessel interactions. The potential link between these effects was examined in an animal model of vascular injury rich in inflammatory cells: the placement of endovascular metal stents in rabbit iliac arteries. Monocyte adhesion stimulated by early focal thrombus was maximal after 3 days, with infiltrating monocytes and intimal cell proliferation maximal after 7 days. Tissue monocyte number dictated cell proliferation at each time point (R2 = .92, P < .0001). Heparin reduced both early monocyte adhesion as well as monocyte infiltration within the neointima 7 and 14 days after stent placement. Reductions in adherent and tissue monocytes were commensurate with reductions in intimal cell proliferation and intimal thickening. At 14 days, heparin's inhibition of mononuclear cell adhesion was correlated with its suppression of intimal thickening (R2 = .82, P < .0001). Monocytes have been hypothesized to serve as markers, initiators, and promoters of arterial occlusive diseases. Heparin's ability to inhibit mononuclear cell adhesion and penetration and reduce neointimal size and cell proliferation after vascular injury may further implicate monocytes in the pathogenesis of neointimal hyperplasia after mechanical arterial injury.

Monocyte Recruitment and Neointimal Hyperplasia in Rabbits: Coupled Inhibitory Effects of Heparin

The biology and pharmacology of PGD2.

Reduction in prostacyclin platelet receptors in active spontaneous angina

Acute hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate (FDP), an agent that is supposed to restore anaerobic glycolytic flux in the ischemic myocardium, were studied in 40 patients with acute myocardial infarction who were grouped into 4 subsets: subset 1, normal (15 mm Hg or less) pulmonary artery (PA) wedge pressure and normal (35 g-m/m2 or greater) left ventricular (LV) stroke work index; subset 2, elevated (more than 15 mm Hg) PA wedge pressure and normal LV stroke work index; subset 3, normal PA wedge pressure and reduced (less than 35 g-m/m2) LV stroke work index; subset 4, elevated PA wedge pressure and LV stroke work index moderately reduced to a range between 16 and 34 g-m/m2. Patients were randomized into an FDP (250 mg/kg body weight in isotonic saline solution intravenously in 20 minutes) and into a placebo group. Each subset contained 5 FDP- and 5 placebo-treated patients. After basal measurements, hemodynamic measurements were reassessed at 60, 90 and 120 minutes from the infusions, while a standard 12-lead electrocardiogram was recorded in the basal state and 120 minutes after infusion. Nonsignificant hemodynamic change was observed in the placebo subsets, and FDP failed to exert any effect in subsets 1, 2 and 3. A 24% (p less than 0.02) increase in cardiac index occurred 60 minutes after FDP in subset 4. LV stroke work index also increased, while PA wedge pressure remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate in acute myocardial infarction.

Over past years, there has been a world-wide increase in oral anticoagulant treatment (OAT). This study was aimed at evaluating the efficacy and safety of OAT managing in a real-practice situation. Nine hundred and three consecutive unselected patients referred for the control of OAT to the Anticoagulation Clinic of the University of Florence were studied. The total follow-up period was 1679 patient-years. The rate of total, major and fatal bleeding events was 5.0, 1.1 and 0.06 per 100 patient-years, respectively. In patients with a target International Normalized Ratio (INR) ≥ 3, a significantly higher rate of bleeding (P=0.02) with respect to patients with a target INR<3 was observed. The rate of all thrombotic events was 3.8 per 100 patient-years. The rate of major and fatal thrombotic events were 2.4 and 0.4 per 100 patient-years, respectively. At INR ≥ 4.5 the rate of bleeding was significantly higher (P=0.005) than at lower INR. At INR < 2 the rate of all thrombotic events was significantly higher (P=0.00001) with respect to more elevated intensities of anticoagulation. A low incidence of complications may be obtained even in elderly outpatients on OAT followed at an anticoagulation clinic.

Low rate of bleeding and thrombotic complications of oral anticoagulant therapy independent of age in the real-practice of an anticoagulation clinic.

The management of asymptomatic overanticoagulation with low dose vitamin K1 is recommended in patients taking oral anticoagulants, independently of the type of coumarin being administered. To evaluate the safety and effectiveness of this practice we observed 127 patients on warfarin and 14 on acenocoumarol, who received 2 mg oral vitamin K1 on at least one occasion. At the first measurement, international normalized ratio (INR) mean values were significantly lower in patients on acenocoumarol than in patients on warfarin (p=0.0001) and all patients on acenocoumarol showed INR values below the therapeutic range. Vitamin K1 should be used cautiously in patients being anticoagulated with acenocoumarol.

Safety and effectiveness of low dose oral vitamin K1 administration in asymptomatic out-patients on warfarin or acenocoumarol with excessive anticoagulation.

A. Lombardi

Papers

Reduction in prostacyclin platelet receptors in active spontaneous angina

Hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate in acute myocardial infarction.

Low rate of bleeding and thrombotic complications of oral anticoagulant therapy independent of age in the real-practice of an anticoagulation clinic.

Safety and effectiveness of low dose oral vitamin K1 administration in asymptomatic out-patients on warfarin or acenocoumarol with excessive anticoagulation.

Hemodynamic effects of digoxin in acute myocardial infarction in man: a randomized controlled trial.