Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

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Guidelines and Expert Consensus Documents summarize and\ud evaluate all available evidence with the aim of assisting\ud physicians in selecting the best management strategy for an\ud individual patient suffering from a given condition, taking\ud into account the impact on outcome and the risk benefit\ud ratio of diagnostic or therapeutic means. Guidelines are no\ud substitutes for textbooks and their legal implications have\ud been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily\ud practice. However, the ultimate judgement regarding the\ud care of an individual patient must be made by his/her\ud responsible physician(s).\ud The recommendations for formulating and issuing ESC\ud Guidelines and Expert Consensus Documents can be found\ud on the ESC website (http://www.escardio.org/knowledge/\ud guidelines/rules).\ud Members of this Task Force were selected by the European\ud Society of Cardiology (ESC) and the European Association for\ud Cardio-Thoracic Surgery (EACTS) to represent all physicians\ud involved with the medical and surgical care of patients\ud with coronary artery disease (CAD). A critical evaluation\ud of diagnostic and therapeutic procedures is performed\ud including assessment of the risk benefit ratio. Estimates\ud of expected health outcomes for society are included,\ud where data exist. The level of evidence and the strength\ud of recommendation of particular treatment options are\ud weighed and graded according to predefined scales, as\ud outlined in Tables 1 and 2.\ud The members of the Task Force have provided disclosure\ud statements of all relationships that might be perceived as\ud real or potential sources of conflicts of interest. These\ud disclosure forms are kept on file at European Heart House,\ud headquarters of the ESC. Any changes in conflict of interest\ud that arose during the writing period were notified to the ESC.\ud The Task Force report received its entire financial support\ud from the ESC and EACTS, without any involvement of the\ud pharmaceutical, device, or surgical industry.\ud ESC and EACTS Committees for Practice Guidelines are\ud responsible for the endorsement process of these joint\ud Guidelines. The finalized document has been approved by all\ud the experts involved in the Task Force, and was submitted to\ud outside specialists selected by both societies for review. The\ud document is revised, and finally approved by ESC and EACTS and subsequently published simultaneously in the European\ud Heart Journal and the European Journal of Cardio-Thoracic\ud Surgery.\ud After publication, dissemination of the Guidelines is of\ud paramount importance. Pocket-sized versions and personal\ud digital assistant-downloadable versions are useful at the\ud point of care.\ud Some surveys have shown that the intended users are\ud sometimes unaware of the existence of guidelines, or simply\ud do not translate them into practice. Thus, implementation\ud programmes are needed because it has been shown that\ud the outcome of dis...

In asymptomatic degenerative MR, LV longitudinal function and LA volume are the main determinants of BNP release. BNP is a powerful independent predictor of cardiac events. Measurement of plasma BNP may help to improve risk stratification and management of asymptomatic patients with degenerative MR.

AimThe exercise Doppler echocardiographic stress test can be of interest in the management of asymptomatic patients with primary mitral regurgitation (MR). The resting brain natriuretic peptide (BNP) level is a good surrogate marker of the consequences of MR and is a powerful predictor of outcome. The incremental prognostic value of BNP response during exercise is unknown. We aimed to identify the determinants of exercise BNP level and to evaluate its prognostic value in asymptomatic patients with primary MR. Methods and resultsComprehensive resting and exercise transthoracic Doppler echocardiography was performed in 113 consecutive asymptomatic patients with moderate to severe degenerative MR and preserved left ventricular (LV) function. Blood samples were collected both at rest and during exercise. The BNP level significantly increased from rest to exercise (P , 0.0001). The independent determinants of exercise BNP were resting E/Ea ratio (P ¼ 0.043), indexed left atrial volume (P ¼ 0.022), and exercise LV global longitudinal strain (P ¼ 0.001). There was a significant graded relationship between increasing BNP level at exercise (according to tertiles) and increased incidence of cardiac events (death, heart failure, mitral valve surgery driven by symptoms, or LV dilatation/dysfunction onset) (1 year, 11 + 5% vs. 14 + 6% vs. 43.5 + 9%; 2 years, 21 + 7% vs. 40 + 8% vs. 67 + 9%; in tertiles 1, 2 and 3, respectively). On multivariable analysis, after adjustment for demographic and echocardiographic data and for resting BNP level, exercise BNP remained significantly associated with increased risk of cardiac events during the follow-up (hazard ratio 2.8 and 3.4, P ¼ 0.041 and 0.023, for tertiles 2 and 3, as compared with tertile 1). ConclusionsIn asymptomatic patients with primary MR, exercise BNP level provides incremental prognostic value beyond what is achieved by demographic and echocardiographic data and resting BNP level. Patients with elevated exercise BNP should be considered at high risk of reduced cardiac event-free survival.--

Background Bariatric surgery is currently the only effective treatment with long‐lasting results to treat severe obesity. Objectives We performed a pilot study to evaluate the feasibility, safety and efficacy of percutaneous distal embolization of the left gastric artery (LGA) using a transradial approach. Methods and Results We recruited seven severely obese male patients (mean age 48 ± 7 years) referred for diagnostic coronary angiography. Mean baseline weight was 160 ± 27 kg and body mass index was of 52 ± 8 kg/m2. We successfully injected 300–500 μm polyvinyl alcohol particles using 5Fr catheters and all distal LGA were occluded at the end of procedures. Mean procedure duration was 24 ± 13 min and mean fluoroscopy time was 10 ± 5 min. Six patients reported mild transient epigastric discomfort, which resolved with proton pump inhibitors. At 2 months, the average weight loss was of 7 ± 6 kg (median loss: −10 kg [−2, −11]), 6 ± 12 kg (median loss: −9 kg [−16, +4]) at 6 months and 13 ± 17 kg (median loss: −11 kg [0, −25]) up to 12 months after index procedures. Conclusion Percutaneous transradial LGA embolization appears to be a promising technique to reduce the obesity burden. Randomized trials are required to further delineate the risk/benefit ratio, potential clinical indications and long term results.

Background: Takotsubo syndrome (TT) and myocardial infarction (MI) share numerous similarities in clinical presentation, ECG modifications and biomarker elevation. We sought to determine whether the ratio of highsensitivity cardiac troponin T (hs-TnT) to the myocardial fraction of creatine kinase (CKMB) could be a potent discriminator between TT and MI patients. Methods: We separately present analysis of data from retrospective files and prospectively recruited patients presenting with TT (35 retrospective and 42 prospective), NSTEMI (48 retrospective and 75 prospective) and STEMI (20 retrospective and 39 prospective). We compared ratios of hs-TnT to CKMB on admission to the hospital between TT, NSTEMI and STEMI patients. Receiver operating characteristic (ROC) curves were analysed to determine optimal cut-off values. Conclusion: hs-TnT/CKMB ratio is a novel, readily available parameter that could be used alongside clinical risk scores, other biomarkers and ECG findings to discriminate between TT and MI.

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