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ESC Guidel<strong>in</strong>es 2911<br />

CI confidence <strong>in</strong>terval<br />

COX cyclo-oxygenase<br />

CPG Committee for Practice Guidel<strong>in</strong>es<br />

CRP C-reactive prote<strong>in</strong><br />

CRT cardiac resynchronization therapy<br />

ECG electrocardiographic/electrocardiogram<br />

EF ejection fraction<br />

EMS emergency medical system<br />

ESC European Society <strong>of</strong> Cardiology<br />

FMC first medical contact<br />

GP glycoprote<strong>in</strong><br />

h hour<br />

HDL high-density lipoprote<strong>in</strong><br />

IABP <strong>in</strong>tra-aortic balloon pump<br />

ICCU Intensive Cardiac Care Unit<br />

ICD implantable cardioverter–defibrillator<br />

INR <strong>in</strong>ternational normalized ratio<br />

i.v. <strong>in</strong>travenous<br />

LDL low-density lipoprote<strong>in</strong><br />

LMWH low-molecular-weight hepar<strong>in</strong><br />

LV left ventricular<br />

m<strong>in</strong> m<strong>in</strong>ute<br />

MBG <strong>myocardial</strong> blush grade<br />

MRI magnetic resonance imag<strong>in</strong>g<br />

NSAID non-steroidal anti-<strong>in</strong>flammatory drug<br />

NYHA New York Heart Association<br />

OR odds ratio<br />

PCI percutaneous coronary <strong>in</strong>tervention<br />

PDA personal digital assistant<br />

PET positron emission tomography<br />

s seconds<br />

s.c. subcutaneous<br />

SCD sudden cardiac death<br />

SPECT s<strong>in</strong>gle-photon emission computed tomography<br />

STEMI <strong>acute</strong> ST-segment elevation <strong>myocardial</strong> <strong><strong>in</strong>farction</strong><br />

TIMI thrombolysis <strong>in</strong> <strong>myocardial</strong> <strong><strong>in</strong>farction</strong><br />

t-PA tissue plasm<strong>in</strong>ogen activator<br />

VF ventricular fibrillation<br />

VT ventricular tachycardia<br />

A. Preamble<br />

Guidel<strong>in</strong>es and Expert Consensus Documents summarize and<br />

evaluate all currently available evidence on a particular issue with<br />

the aim <strong>of</strong> assist<strong>in</strong>g physicians <strong>in</strong> select<strong>in</strong>g the best management<br />

strategies for a typical patient, suffer<strong>in</strong>g from a given condition,<br />

tak<strong>in</strong>g <strong>in</strong>to account the impact on outcome, as well as the risk/<br />

benefit ratio <strong>of</strong> particular diagnostic or therapeutic means. Guidel<strong>in</strong>es<br />

are no substitutes for textbooks. The legal implications <strong>of</strong><br />

medical guidel<strong>in</strong>es have been discussed previously.<br />

A great number <strong>of</strong> Guidel<strong>in</strong>es and Expert Consensus Documents<br />

have been issued <strong>in</strong> recent years by the European Society<br />

<strong>of</strong> Cardiology (ESC) as well as by other societies and organizations.<br />

Because <strong>of</strong> the impact on cl<strong>in</strong>ical practice, quality criteria for the<br />

development <strong>of</strong> guidel<strong>in</strong>es have been established <strong>in</strong> order to<br />

make all decisions transparent to the user. The recommendations<br />

for formulat<strong>in</strong>g and issu<strong>in</strong>g ESC Guidel<strong>in</strong>es and Expert Consensus<br />

Documents can be found on the ESC website (http://www.<br />

escardio.org/knowledge/guidel<strong>in</strong>es/rules).<br />

In brief, experts <strong>in</strong> the field are selected and undertake a<br />

comprehensive review <strong>of</strong> the published evidence for management<br />

and/or prevention <strong>of</strong> a given condition. Unpublished cl<strong>in</strong>ical trial<br />

results have not been taken <strong>in</strong>to account. A critical evaluation <strong>of</strong><br />

diagnostic and therapeutic procedures is performed <strong>in</strong>clud<strong>in</strong>g<br />

assessment <strong>of</strong> the risk/benefit ratio. Estimates <strong>of</strong> expected health<br />

outcomes for larger societies are <strong>in</strong>cluded, where data exist. The<br />

level <strong>of</strong> evidence and the strength <strong>of</strong> recommendation <strong>of</strong> particular<br />

treatment options are weighed and graded accord<strong>in</strong>g to predef<strong>in</strong>ed<br />

scales, as outl<strong>in</strong>ed <strong>in</strong> Tables 1 and 2.<br />

The experts <strong>of</strong> the writ<strong>in</strong>g panels have provided disclosure statements<br />

<strong>of</strong> all relationships they may have which might be perceived<br />

as real or potential sources <strong>of</strong> conflicts <strong>of</strong> <strong>in</strong>terest. These disclosure<br />

forms are kept on file at the European Heart House, headquarters<br />

<strong>of</strong> the ESC. Any changes <strong>in</strong> conflict <strong>of</strong> <strong>in</strong>terest that arise dur<strong>in</strong>g the<br />

writ<strong>in</strong>g period must be notified to the ESC. The Task Force report<br />

was entirely supported f<strong>in</strong>ancially by the ESC and was developed<br />

without any <strong>in</strong>volvement <strong>of</strong> the <strong>in</strong>dustry.<br />

The ESC Committee for Practice Guidel<strong>in</strong>es (CPG) supervises<br />

and coord<strong>in</strong>ates the preparation <strong>of</strong> new Guidel<strong>in</strong>es and Expert<br />

Consensus Documents produced by Task Forces, expert groups,<br />

or consensus panels. The Committee is also responsible for the<br />

endorsement process <strong>of</strong> these Guidel<strong>in</strong>es and Expert Consensus<br />

Documents or statements. Once the document has been f<strong>in</strong>alized<br />

and approved by all the experts <strong>in</strong>volved <strong>in</strong> the Task Force, it is<br />

submitted to outside specialists for review. The document is<br />

revised, and f<strong>in</strong>ally approved by the CPG and subsequently<br />

published.<br />

After publication, dissem<strong>in</strong>ation <strong>of</strong> the message is <strong>of</strong> paramount<br />

importance. Pocket-sized versions and personal digital assistant<br />

(PDA)-downloadable versions are useful at the po<strong>in</strong>t <strong>of</strong> care.<br />

Some surveys have shown that the <strong>in</strong>tended end-users are sometimes<br />

not aware <strong>of</strong> the existence <strong>of</strong> guidel<strong>in</strong>es, or simply do not<br />

translate them <strong>in</strong>to practice, so this is why implementation<br />

programmes for new guidel<strong>in</strong>es form an important component<br />

<strong>of</strong> the dissem<strong>in</strong>ation <strong>of</strong> knowledge. Meet<strong>in</strong>gs are organized by<br />

the ESC, and directed towards its member National Societies<br />

and key op<strong>in</strong>ion leaders <strong>in</strong> Europe. Implementation meet<strong>in</strong>gs can<br />

also be undertaken at national levels, once the guidel<strong>in</strong>es have<br />

been endorsed by the ESC member societies, and translated <strong>in</strong>to<br />

the national language. Implementation programmes are needed<br />

because it has been shown that the outcome <strong>of</strong> disease may be<br />

favourably <strong>in</strong>fluenced by the thorough application <strong>of</strong> cl<strong>in</strong>ical<br />

recommendations.<br />

Thus, the task <strong>of</strong> writ<strong>in</strong>g Guidel<strong>in</strong>es or Expert Consensus documents<br />

covers not only the <strong>in</strong>tegration <strong>of</strong> the most recent research,<br />

but also the creation <strong>of</strong> educational tools and implementation<br />

programmes for the recommendations. The loop between cl<strong>in</strong>ical<br />

research, writ<strong>in</strong>g <strong>of</strong> guidel<strong>in</strong>es, and implement<strong>in</strong>g them <strong>in</strong> cl<strong>in</strong>ical<br />

practice can then only be completed if surveys and registries<br />

are performed to verify that real-life daily practice is <strong>in</strong> keep<strong>in</strong>g<br />

with what is recommended <strong>in</strong> the guidel<strong>in</strong>es. Such surveys<br />

and registries also make it possible to evaluate the impact <strong>of</strong><br />

implementation <strong>of</strong> the guidel<strong>in</strong>es on patient outcomes. Guidel<strong>in</strong>es

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