New pan-European guidelines on the treatment of diabetes, cardiovascular and valvular heart diseases published
Published in the print version of the European Heart Journal (EHJ)  today (Tuesday 6 February), the guidelines for valvular heart disease (VHD) highlight what should be happening according to the best available evidence from clinical trials.
Professor Alec Vahanian, chair of the European Society of Cardiology (ESC) task force responsible for the VHD guidelines and head of the cardiology department of the Bichât Hospital in Paris, France, said: “Data from the recent Euro Heart Survey on VHD show that there is a real gap between the existing guidelines and their effective application. It is for this reason that we have produced these guidelines, which are the first European guidelines on this topic. It is a unique feature of these guidelines that we have been able to integrate the current practice in Europe and emphasise particular issues that were not adequately performed in current practice.”
The guidelines on diabetes, pre-diabetes and cardiovascular diseases (CVD), also published recently in the EHJ , underline the fact that diabetes and cardiovascular heart diseases often go hand in hand, and that physicians should check for both conditions when they see a patient who appears to have only one of them.
Professor Eberhard Standl, co-chair of the task force for the diabetes and CVD guidelines, chair of the Diabetes Research Institute in Munich and president-elect of the International Diabetes Federation of Europe, said: “We are dealing with two sides of the same coin: diabetes on one side and cardiovascular diseases on the other. The great merit of these guidelines is that they recognise this. Cardiologists and diabetologists from all over Europe were involved in writing these guidelines and we hope that they will improve the management and care of the millions of patients who have both cardiovascular and metabolic diseases in common.”
Experts from different European countries and from different specialities, such as clinical, surgical and echocardiographical, also collaborated to write the VHD guidelines. A number of diseases or disorders of the valves in the heart come under the title of VHD, and they include damage caused by diseases such as rheumatic fever, or degenerative conditions often caused by old age. One of the problems when treating VHD, or producing guidelines on its treatment, is the lack of evidence on best practice.
Prof Vahanian said: “When compared with other heart diseases, there are few trials in the field of VHD, and randomised trials are particularly scarce. Our guidelines are based on the evidence that exists and the consensus of all the experts who were involved in each step of the writing process. We hope that individual countries will recognise the quality of these guidelines and adopt them so that they become widely used throughout Europe for the benefit of patients.”
The VHD guidelines deal with every aspect of treatment from patient evaluation through to surgery, other therapies and management during pregnancy. Prof Vahanian said that one important recommendation concerned the use of stress testing, when the function of the heart is evaluated while it is working harder as the patient exercises. “It is important that stress testing is used more often in order to ensure that patients who are not symptomatic receive the right treatment,” he said.
The guidelines also point to the need to use echocardiography as the key technique to confirm a diagnosis of VHD. However, some countries provide better access to echocardiography facilities for patients than do other countries.
“Another important point concerns the treatment of elderly patients,” said Prof Vahanian. “VHD occurs most frequently in the elderly, yet the Euro Heart Survey showed that many elderly patients were not even considered for surgery by physicians, for reasons that were often unjustified. So the guidelines stress the need for precise risk stratification before decisions are made about treatment for elderly patients.
“Increasingly we are seeing patients with VHD who have had surgery previously for other heart conditions. They represent about a third of patients that we see. In the guidelines we say that this is a group of patients that should be monitored better, because the Euro Heart Survey showed there were discrepancies between guidelines and practice.”
A joint task force of the ESC and the European Association for the Study of Diabetes (EASD) wrote the guidelines on diabetes, pre-diabetes and CVD. The authors believe there is still much to be done to improve the treatment of patients with these disorders. Among the issues that they highlight is screening for undiagnosed diabetes.
Prof Standl said: “Recent estimates suggest that 195 million people throughout the world have diabetes. This number will increase to 330, maybe even 500 million, by 2030. Up to 50 per cent of all patients with type 2 diabetes are undiagnosed since they remain asymptomatic for many years. Detecting these patients is important for public health and everyday clinical practice. We have not recommended mass screening for asymptomatic diabetes until there is evidence that the prognosis of such patients will improve by early detection and treatment. Indirect evidence suggests that screening might be beneficial, improving possibilities for the prevention of cardiovascular complications.”
Since many patients with CAD may have asymptomatic diabetes, or pre-diabetes (the precursor to the full-blown disease), the guidelines recommend that patients should have an oral glucose tolerance test if their diabetic status is unknown. In addition, every patient with diabetes should be screened for CAD, so that they can receive the right treatment.
“The costs associated with diabetes make up a considerable share of the resources spent on healthcare throughout Europe. As the most important cost drivers are complications caused by the disease, proper management of complications is essential,” concluded Prof Standl.
 Guidelines on the management of valvular heart disease. The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. European Heart Journal, doi:10.1093/eurheartj/ehl428
 Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). European Heart Journal, doi:10.1093/eurheartj/ehl260
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