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May 27

“2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries”1

“2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries”1

Abstract

Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in selecting the bestmanagement strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate. A great number of guidelines have been issued in recent years by the European Society of Cardiology (ESC), by the European Society of Vascular Surgery (ESVS) and by the European Stroke Organization (ESO), as well as by other societies and organisations. 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 ESC Guidelines can be found on the ESCWebsite  ESC Guidelines represent the oficial position of the ESC on a given topic and are regularly updated. Members of this Task Force were selected by the ESC, including representation from the ESVS and ESO 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 management of a given condition according to ESC Committee for Practice Guidelines (CPG) policy and approved by the ESVS and ESO. A critical evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk–benefit ratio. The level of evidence and the strength of the recommendation of particular management options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2. The experts of the writing and reviewing panels provided declaration of interest forms for all relationships that 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 ESC Website (http:// www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period were notified to the ESC and updated. The Task Force received its entire financial support from the ESC and ESVS without any involvement from the healthcare industry. The ESC CPG supervises and coordinates the preparation of new Guidelines. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts, and in this case by ESVS- and ESO-appointed experts. After appropriate revisions the Guidelines are approved by all the experts involved in the Task Force. The finalized document is approved by the CPG and ESVS for publication in the European Heart Journal and in the European Journal of Vascular and Endovascular Surgery. The Guidelines were developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating. The task of developing ESC Guidelines in collaboration with ESVS also includes the creation of educational tools and implementation programmes for the recommendations including condensed pocket guideline versions, summary slides, booklets with essential messages, summary cards for non-specialists and an electronic version for digital applications (smartphones, etc.). These versions are abridged and thus, if needed, one should always refer to the full text version, which is freely available via the ESC Website and hosted on the EHJ Website. The National Societies of the ESC are encouraged to endorse, translate and implement all ESC Guidelines. 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 guidelines, disseminating them and implementing them into clinical practice. Health professionals are encouraged to take the ESC Guidelines developed in collaboration with ESVS fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, the ESC Guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient or the patient’s caregiver where appropriate and/or necessary. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

Comentario

La guía aquí presentada es la actualización de la primera guía de práctica clínica de la ESC sobre la enfermedad vascular periférica (EVP) publicada en 2011.  En ella se incide en la importancia de que todos los médicos, independientemente de su especialidad, estén sensibilizados y conozcan la naturaleza común de la enfermedad arterioesclerótica y los factores de riesgo en los diferentes territorios vasculares. La guía recomienda el cribado de EVP en los pacientes con enfermedad cardiaca o cerebrovascular y viceversa, ya que estas dos localizaciones son las causas de mortalidad más frecuentes entre los pacientes con EVP.

En el documento se repasan detalladamente cada una de las EVP, cardiaca, cerebral y de miembros, se resumen las novedades con respecto a la edición previa y se incluyen mensajes clave de cada capítulo. Con respecto a la EAP de miembros inferiores cabe destacar la introducción del término de “enfermedad enmascarada”. En el tratamiento médico, se mantiene la recomendación de antiagregantes en caso de enfermedad sintomática y emerge con fuerza la recomendación del tratamiento con estatinas y ejercicio físico supervisado. La guía señala que solamente en caso de ausencia de mejoría clínica con el tratamiento conservador y en casos en que la claudicación resulte limitante para la actividad diaria del paciente, se plantee el tratamiento revascularizador.

Con respecto a la isquemia critica, apoya la utilización de la clasificación WIfI (W: herida; I: isquemia; fI: infección del pie) que estratifica el riesgo de amputación y recomienda revascularización sistemática siempre que sea posible sin especificar técnica de elección. En el caso de isquemia aguda, remarca que la indicación de cirugía urgente es para el caso de afectación neurológica y que si esta no existe se puede retrasar unas horas, lo que permite un estudio completo del paciente

Poco después de publicarse esta guía, se han publicado 2 estudios de gran relevancia en el tratamiento de la enfermedad arterial periférica. El primero, estudio COMPASS, muestra que la combinación de rivaroxabán a dosis bajas (2,5 mg 2 veces al dáa) con 100 mg diarios de ácido acetilsalicílico reduce significativamente los eventos cardiovasculares mayores y los eventos en relación con la isquemia de los miembros inferiores, como las amputaciones, en pacientes con enfermedad arterial periférica. El segundomuestra que el evolocumab, un inhibidor de la PCSK9, reduce significativamente el riesgo de eventos cardiovasculares en pacientes con enfermedad arterial periférica.

  1. Aboyans, Victor; et al; 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteri; European Heart Journal, 2018; 36, 763-821.

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