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National Guidelines for Cardiac Care – summary

These guidelines contain recommendations for cardiac care and include diagnostics, treatment and rehabilitation within coronary disease, diseases of the heart valve, arrhythmia, heart failure, in addition to genetic cardiovascular diseases and congenital heart defects.

The aim of the recommendations is to provide guidance for group-level decisions.

The guidelines also include evaluations of the financial and organisatory consequences for some of the recommendations, in addition to follow-up indicators.

These guidelines are a revision of previous national guidelines for cardiac care from 2008 and 2011. The revised guidelines are based on the need for guidance within healthcare and medical treatment, and therefore primarily include those areas and measures where there are great differences in practice or, where the need for quality development is high. A number of areas that were included in previous versions of the guidelines have already been implemented within healthcare and medical treatment and are therefore not included in the revised version.

Central recommendations

Coronary Disease

A blood clot that completely stops the blood flow through a coronary artery is treated via Reperfusion Therapy, to reinstate circulation in the artery. The treatment is usually balloon angioplasty and the insertion of metal netting (known as PCI, “Percutaneous coronary intervention”), but also administration of medicine to dissolve the blood clot (thrombolysis). If the treatment can be administered in reasonable time, PCI is the first step for myocardial infarction with ST elevation. Healthcare and medical treatment should however be able to offer thrombolysis within 30 minutes after the electrocardiogram (ECG) for those cases where primary PCI is not available within 120 minutes.

In the majority of regions in the country, it is currently already possible to perform PCI within a reasonable time frame. However the recommendation means that the organisation may need to be reviewed in those areas where it is not possible to perform PCI within 120 minutes.

For a person with complicated coronary disease, the choice of treatment can have a large effect on survival and the risks of myocardial infarction and relapse. It is therefore important for different specialists to assume a joint position regarding the most suitable treatment during participation at a multidisciplinary conference. This is particularly applicable in those cases and states of health where the choice of method for revascularisation (PCI or heart bypass surgery) is not given.

To obtain a well-functioning structure at multidisciplinary conferences, the recommendations can initially entail certain financial and organisatory changes within healthcare and medical treatment.

Diseases of the heart valve

Pronounced, symptomatic aortic stenosis, is a disease of the heart valve and when left untreated, has a high mortality rate and influence on the function and quality-of-life. For this condition, the current standard treatment is open heart valve surgery using cardiopulmonary bypass. Healthcare and medical treatment should however offer the implantation of a transcatheter aortic heart valve (TAVI) to persons with pronounced, symptomatic aortic stenosis who are deemed to be of such high risk that bypass surgery is unsuitable.

This will initially entail increased costs for healthcare and medical treatment. The costs for the actual valve however, can be expected to reduce over time as a result of increased volume and competitive pricing.

Arrhythmia

Atrial fibrillation conveys an increased risk of suffering from a thromboembolism (disease caused by blood clots) and most of all, cerebral infarction (ischemic stroke). Blood-thinning medication (anticoagulant) is administered to prevent strokes. Whether or not the treatment shall be administered is based on the matter of how great a risk there is for a person with atrial fibrillation to suffer from an ischemic stroke.

For persons with atrial fibrillation and increased risk of ischemic stroke, healthcare and medical treatment should offer anticoagulation treatment with apixaban, dabigatran, rivaroxaban or warfarin. As for persons with atrial fibrillation without risk of stroke, they should not be treated using anticoagulants. Furthermore, healthcare and medical treatment should not offer therapy using acetylsalicylic acid for atrial fibrillation and an increased risk of stroke, as this has worse effects than therapy using apixaban, dabigatran, rivaroxaban or warfarin.

If new peroral anticoagulants are widely introduced in both new prescriptions and treatment of those patients who do not currently receive therapy with anticoagulants, initial costs for healthcare and medical treatment will increase. However during the same period, costs for the medical treatment of strokes are estimated to reduce. In the long run, the recommendations will lead to savings – first and foremost through reduced costs to stroke healthcare. 

Heart failure

Heart failure increases the risks for premature death and decreased quality of life. It can lead to fear of movement, reduced daily activity and reduced physical fitness. Persons with chronic heart failure and prolonged activation of ventricular contraction (such as left bundle-branch block) should be offered treatment with cardiac resynchronisation therapy. This treatment has good effects on symptoms and survival, however considerable differences in practice exist between the different county councils. The recommendation is most likely to lead to more patients being offered cardiac resynchronisation therapy, however it is difficult to judge the exact number.

Physical training within cardiac rehabilitation is a form of therapy that is currently under-used for cases of heart failure and should be made available to more patients. The recommendation can lead to measurable increased costs to healthcare and medical treatment, in addition to certain organisatory changes so more persons are able to be offered this treatment.

Persons at an increased risk of serious heart palpitations or who have been affected by life-threatening cardiac arrhythmias can be treated by an implantable cardioverter defibrillator (ICD) to prevent sudden death. However, an ICD which produces defibrillator shocks can entail risks of lengthened pain and suffering, as well as concerns for persons in the latter stages of life. Healthcare and medical treatment should therefore offer these patients discussions about the significance and possibility of inactivation, the defibrillator's shock function throughout the course of the disease – however most of all, during the latter stages of life.

The National Board of Health and Welfare estimates that the recommendation will not lead to any large financial consequences for healthcare and medical treatment. However the recommendation is deemed to have a certain impact on the organisation of healthcare and medical treatment.

Genetic cardiovascular diseases and congenital heart defects.

There is currently an underdiagnosis of genetic cardiovascular diseases. A large proportion of those with these diseases are young and in otherwise healthy persons. Sudden death can be the first manifestation. To identify people with genetic cardiovascular diseases, healthcare and medical treatment should offer what is known as “cascade screening”. This also means that with help from clinical or genetic testing, healthcare and medical treatment can conduct a family investigation based on a person with a known genetic cardiovascular disease.

The recommendation is estimated to initially entail increased costs to healthcare and medical treatment, however the cost will then reduce as the number of undiagnosed persons will have reduced.

Many adults with congenital heart defects are not followed up on by specialist cardiac healthcare. These persons are exposed to an increased risk of premature death and an increased need for more acute treatment. Healthcare and medical treatment should therefore offer a follow up for adults with congenital heart defects within the field of GUCH (grown up congenital heart disease).

The National Board of Health and Welfare estimate that the implications of recommendation will need an increased reinforcement of healthcare and medical treatment personnel with specialist competence, to ensure that they will be able to meet the increased number of visits to different GUCH centres.

Follow-up indicators

In connection with the work on these guidelines, the National Board of Health and Welfare has also updated and supplemented the existing indicators for cardiac care. The indicators are intended to reflect the most important recommendations of the guidelines, as well as different aspects of good and equal healthcare. Data for the indications are collected from quality registers within cardiac care and the National Board of Health and Welfare National Patient Database.

The National Board of Health and Welfare have also established target levels for some of the indicators. The target levels state the portion of a patient group that should be eligible for a certain form of examination or treatment.