Recent scientific documents from the European Heart Rhythm Association (EHRA)

The Scientific Documents Committee of European Heart Rhythm Association (EHRA) is responsible for the planning, initiation, reviewing, and publishing of scientific statements addressing areas of interest to EHRA members and the wider cardiology profession. The goal of the committee work is to provide sound advice, based on scientific data and generated by experts in the field, in emerging areas relevant to the management of arrhythmias in Europe. A growing number of documents is/will be generated as joint statements with other European Society of Cardiology (ESC) associations or working groups, or with other arrhythmia societies: a long-standing cooperation with Heart Rhythm Society (HRS) has been generating many joint scientific documents per year, and also with Asia Pacific Heart Rhythm Society (APHRS). This editorial is a brief summary of the recently published and also ongoing EHRA scientific documents. Several new devices for the treatment of heart failure (HF) patients have been introduced and are increasingly used in clinical practice or are under clinical evaluation in either observational and/or randomized clinical trials. These devices include cardiac contractility modulation, spinal cord stimulation, carotid sinus nerve stimulation, cervical vagal stimulation, intracardiac atrioventricular nodal vagal stimulation, and implantable haemodynamic monitoring devices. This document is a detailed review of such new devices used in HF treatment.1 Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. This position paper offers some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, the authors suggest further improvements that can be implemented by both the physicians and the industry in the future.2 This expert consensus by EHRA, HRS, and APHRS document addresses the indications for diagnostic testing, the present state of prognostic risk stratification, and the treatment strategies that have been demonstrated to improve the clinical outcome of patients with ventricular arrhythmias. In addition, this document includes recommendations for referral of patients to centres with specialized expertise in the management of arrhythmias. Wherever appropriate, the reader is referred to other publications regarding the indications for implantable cardioverter-defibrillator (ICD) implantation, catheter ablation, inherited arrhythmia syndromes, congenital heart disease, the use of amiodarone, and the management of patient with ICD shocks, syncope, or those nearing end of life.3 Oral anticoagulants (OACs) including warfarin and new OACs (NOACs) remain the standard therapy when there is no special risk or contraindication to NOACs. However, the option of left LAA occlusion should be discussed with the patient, including risks of the procedure and limited proof of superiority. Patients who refuse NOACs after thorough discussion of current data including limitations may be considered for LAA occlusion. This document reviews the catheter-based methods and their results.4 The changes in the clinical approach to arrhythmia management in acute coronary syndromes (ACS) have been so substantial that EHRA, ACCA, and the EAPCI established a task force to define the current position. The document summarizes the current position, contemporary approaches, and offers recommendations on how to identify ACS patients at risk for arrhythmias; manage tachyarrhythmias and bradyarrhythmias using pharmacological and non-pharmacological, device- and catheter-based approaches including electrical cardioversion, implantation of temporary PMs, programming of ICD, catheter ablation; and implement clinical and referral strategies. These recommendations are provided for acute care and management of ventricular arrhythmias, atrial fibrillation, bradyarrhythmias, and prevention of stroke and embolism in patients with ACS, and arrhythmias developing during coronary interventions and in patients with implanted devices and cardiogenic shock. The task force agrees on that management of intractable arrhythmias requires the team-based approach including specialists in acute cardiac care, interventional cardiology, and electrophysiology.5 The paradigm of evidence-based medicine has led to a more comprehensive decision-making process and most likely to improve outcomes in many patients. However, implementing relevant basic research knowledge in a system of evidence-based medicine appears to be challenging. Furthermore, the current economic climate and the restricted nature of research funding call for improved efficiency of translation from basic discoveries to healthcare delivery. In this document the authors aimed to appraise the broad challenges of translational research in cardiac electrophysiology, highlight the need for improved strategies in the training of translational electrophysiologists, and discuss steps towards building a favourable translational research environment and culture.6 The European Society of Cardiology has played an important role in advancing our understanding of the causes, optimal investigation, and management of syncope through publication of practice guidelines in 2001, 2004, and 2009. The 2009 ESC guidelines recommend the establishment of formal syncope units—either virtual or physical site within a hospital or clinic facility—with access to syncope specialists and specialized equipment. In response, this position paper offers a pragmatic approach to the rationale and requirement for a syncope unit, based on specialist consensus, existing practice, and scientific evidence. The panel consists of specialists who have experience in developing and leading such units representing cardiology, geriatric and general internal medicine, neurology and emergency medicine specialists. This document is addressed to physicians and others in administration, who are interested in establishing a syncope unit in their hospital, so that they can meet the standards proposed by ESC-EHRA-HRS.7 Arrhythmias confer a substantial risk of mortality and morbidity in patients with HF, and this represents a major healthcare burden world-wide. There are at least 15 million patients with HF in Europe alone. To address the management of arrhythmias in HF, a task force was convened by EHRA and HFA, endorsed by HRS and APHRS, with the remit to comprehensively review the published evidence, to publish a joint consensus document on arrhythmias in HF patients, and to provide up-to-date recommendations for use in clinical practice.8 Various documents are at an advance stage of preparation, and publication is anticipated in 2015, to coincide with EHRA Congress 2015. These are summarized as follows. Antithrombotic management of patients undergoing electrophysiological procedures has witnessed major changes due to an increase in the number of procedures and in the knowledge about the role of warfarin and NOACs. The present ‘state of the art’ joint European consensus document, endorsed by the HRS and APHS, covers the antithrombotic management during different ablation procedures, implantation or exchange of cardiac implantable electronical devices as well as the management of peri-interventional bleeding complications. The document strives to be practical and every sub-chapter is followed by recommendations for clinical management. The prevalence of chronic kidney disease (CKD) exceeds 10% in the adult population, with a trend towards increasing prevalence and important implications for clinical management and health policy. Since CKD has profound influences on the risk-benefit profile of many treatments and interventions, it is appropriate to measure and monitor kidney function in any patient with a cardiac disease or rhythm disturbances, such as AF or sustained ventricular tachyarrhythmias. Management of rhythm disturbances and implantable electrical devices in patients with cardiac disease and CKD is complex and requires close collaboration between cardiologists, nephrologists, and other specialists. Considering the need for increasing the awareness of CKD among the community of cardiologists, with specific focus on those dedicated to management of arrhythmic problems, as well as the need to create the basis for collaborative, personalized, patient-centred care, with integration of different healthcare specialists, EHRA in collaboration with HRS and APHRS has promoted the present document, resulting from an interaction between cardiologists and nephrologists. The scope of this paper is to summarize the literature on patients' experience of cardiac arrhythmias and their management and the impact of this on treatment preference. To give advice/recommendations regarding ‘best-practice’ education of patients, tools to aid patient–healthcare professional consultations and links to useful resources for patients. The scientific documents committee of EHRA has been very active, promoting new scientific documents as position statements, many of which are in collaboration with other Associations, Working Groups and learned societies. As evident from the length and breadth of topics covered, a comprehensive coverage of arrhythmias is intended, with the aim to provide ‘state of the art’ consensus on current topics, controversial areas, and offer management options.