ESC Guidelines on the diagnosis and treatment of peripheral artery ...

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Page 4 of 56 CARP Coronary Artery Revascularization Prophylaxis CAS carotid artery stenting CASPAR Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Arterial Disease CASS Coronary Artery Surgery Study CAVATAS CArotid and Vertebral Artery Transluminal Angioplasty Study CEA carotid endarterectomy CHARISMA Clopidogrel for High Atherothrombotic Risk and Ischaemic Avoidance Stabilization, Management and CI confidence interval CLEVER Claudication: Exercise Versus Endoluminal CLI Revascularization critical limb ischaemia CORAL Cardiovascular Outcomes in Renal Atherosclerotic Lesions COURAGE Clinical Outcomes Utilization Revascularization and Aggressive Drug Evaluation CPG Committee for Practice <strong>Guidelines</strong> CREST Carotid Revascularization Endarterectomy vs. CT Stenting Trial computed tomography CTA computed tomography angiography CVD cardiovascular disease DECREASE-V Dutch Echocardiographic Cardiac Risk Evaluation DRASTIC Dutch Renal Artery Stenosis Intervention Cooperative Study DSA digital subtraction angiography DUS duplex ultrasound/duplex ultrasonography EACTS European Association for Cardio-Thoracic Surgery EAS European Atherosclerosis Society ECST European Carotid Surgery Trial EPD embolic protection device <strong>ESC</strong> European Society of Cardiology ESH European Society of Hypertension ESRD end-stage renal disease EUROSCORE European System Evaluation for Cardiac Operative Risk EVA-3S Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis EXACT Emboshield and Xact Post Approval Carotid Stent Trial GALA General Anaesthesia versus Local Anaesthesia for Carotid Surgery GFR glomerular filtration rate GRACE Global Registry of Acute Coronary Events HbA1c glycated haemoglobin HDL high-density lipoprotein HOPE Heart Outcomes Prevention Evaluation HR hazard ratio IC intermittent claudication ICSS International Carotid Stenting Study IMT intima–media thickness ITT intention to treat LDL low-density lipoprotein LEAD lower extremity artery disease MACCEs major adverse cardiac and cerebrovascular events MDCT multidetector computed tomography MONICA Monitoring of Trends and Determinants in Cardiovascular Disease MRA magnetic resonance angiography MRI magnetic resonance imaging NASCET North American Symptomatic Carotid Endarterectomy Trial ONTARGET Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial OR odds ratio PAD peripheral artery diseases PARTNERS Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival PCI percutaneous coronary intervention PET positron emission tomography PRO-CAS Predictors of Death and Stroke in CAS PTA percutaneous transluminal angioplasty RAAS renin–angiotensin–aldosterone system RADAR Randomized, Multicentre, Prospective Study Comparing Best Medical Treatment Versus Best Medical Treatment Plus Renal Artery Stenting in Patients With Haemodynamically Relevant Atherosclerotic Renal Artery Stenosis RAS renal artery stenosis RCT randomized controlled trial REACH Reduction of Atherothrombosis for Continued Health RR risk ratio SAPPHIRE Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy SCAI Society for Cardiovascular Angiography and Interventions SIR Society of Interventional Radiology SPACE Stent-Protected Angioplasty versus Carotid Endarterectomy SPARCL Stroke Prevention by Aggressive Reduction in Cholesterol Levels Study STAR Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function SSYLVIA Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries SVMB Society for Vascular Medicine and Biology TASC TransAtlantic Inter-Society Consensus TIA transient ischaemic attack UEAD upper extremity artery disease VA vertebral artery 1. Preamble <strong>ESC</strong> <strong>Guidelines</strong> <strong>Guidelines</strong> summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies
<strong>ESC</strong> <strong>Guidelines</strong> Page 5 of 56 for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. <strong>Guidelines</strong> are no substitutes but are complements for textbooks and cover the <strong>ESC</strong> Core Curriculum topics. <strong>Guidelines</strong> and recommendations should help the physicians to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible physician(s). A large number of <strong>Guidelines</strong> have been issued in recent years by the European Society of Cardiology (<strong>ESC</strong>) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing <strong>ESC</strong> <strong>Guidelines</strong> can be found on the <strong>ESC</strong> website (http://www. escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writ ing.aspx). <strong>ESC</strong> <strong>Guidelines</strong> represent the official position of the <strong>ESC</strong> on a given topic and are regularly updated. Members of this Task Force were selected by the <strong>ESC</strong> to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for diagnosis, management, and/or prevention of a given condition according to <strong>ESC</strong> Committee for Practice <strong>Guidelines</strong> (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular treatment options were weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2. The experts of the writing and reviewing panels filled in declarations of interest forms of all relationships which might be perceived as real or potential sources of conflicts of interest. These forms were compiled into one file and can be found on the <strong>ESC</strong> Table 1 Classes of recommendations Classes of recommendations Class I Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy. Class IIb Usefulness/efficacy is less well established by evidence/opinion. Class III Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. website (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the <strong>ESC</strong> and updated. The Task Force received its entire financial support from the <strong>ESC</strong> without any involvement from the healthcare industry. The <strong>ESC</strong> CPG supervises and coordinates the preparation of new <strong>Guidelines</strong> produced by Task Forces, expert groups, or consensus panels. The Committee is also responsible for the endorsement process of these <strong>Guidelines</strong>. The <strong>ESC</strong> <strong>Guidelines</strong> undergo extensive review by the CPG and external experts. After appropriate revisions, it is approved by all the experts involved in the Task Force. The finalized document is approved by the CPG for publication in the European Heart Journal. The task of developing <strong>Guidelines</strong> covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines, condensed pocket guidelines versions, summary slides, booklets with essential messages, and electronic version for digital applications (smartphones, etc.), are produced. These versions are abridged and, thus, if needed, one should always refer to the full text version which is freely available on the <strong>ESC</strong> website. The National Societies of the <strong>ESC</strong> are encouraged to endorse, translate, and implement the <strong>ESC</strong> <strong>Guidelines</strong>. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations. Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of <strong>Guidelines</strong>, and implementing them into clinical practice. The <strong>Guidelines</strong> 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 Definition Suggested wording to use Is recommended/is indicated Should be considered May be considered Is not recommended
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