ABI
: ankle–brachial index
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation
AGREE
: Appraisal of Guidelines Research and Evaluation
AHA
: American Heart Association
apoA1
: apolipoprotein A1
apoB
: apolipoprotein B
CABG
: coronary artery bypass graft surgery
CARDS
: Collaborative AtoRvastatin Diabetes Study
CCNAP
: Council on Cardiovascular Nursing and Allied Professions
CHARISMA
: Clopidogrel for High Athero-thrombotic Risk and Ischemic Stabilisation, Management, and Avoidance
CHD
: coronary heart disease
CKD
: chronic kidney disease
COMMIT
: Clopidogrel and Metoprolol in Myocardial Infarction Trial
CRP
: C-reactive protein
CURE
: Clopidogrel in Unstable Angina to Prevent Recurrent Events
CVD
: cardiovascular disease
DALYs
: disability-adjusted life years
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Trial
ED
: erectile dysfunction
eGFR
: estimated glomerular filtration rate
EHN
: European Heart Network
EPIC
: European Prospective Investigation into Cancer and Nutrition
EUROASPIRE
: European Action on Secondary and Primary Prevention through Intervention to Reduce Events
GFR
: glomerular filtration rate
GOSPEL
: Global Secondary Prevention Strategies to Limit Event Recurrence After MI
GRADE
: Grading of Recommendations Assessment, Development and Evaluation
HbA1c
: glycated haemoglobin
HDL
: high-density lipoprotein
HF-ACTION
: Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing
HOT
: Hypertension Optimal Treatment Study
HPS
: Heart Protection Study
HR
: hazard ratio
hsCRP
: high-sensitivity C-reactive protein
HYVET
: Hypertension in the Very Elderly Trial
ICD
: International Classification of Diseases
IMT
: intima-media thickness
INVEST
: International Verapamil SR/Trandolapril
JTF
: Joint Task Force
LDL
: low-density lipoprotein
Lp(a)
: lipoprotein(a)
LpPLA2
: lipoprotein-associated phospholipase 2
LVH
: left ventricular hypertrophy
MATCH
: Management of Atherothrombosis with Clopidogrel in High-risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke
MDRD
: Modification of Diet in Renal Disease
MET
: metabolic equivalent
MONICA
: Multinational MONItoring of trends and determinants in CArdiovascular disease
NICE
: National Institute of Health and Clinical Excellence
NRT
: nicotine replacement therapy
NSTEMI
: non-ST elevation myocardial infarction
ONTARGET
: Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial
OSA
: obstructive sleep apnoea
PAD
: peripheral artery disease
PCI
: percutaneous coronary intervention
PROactive
: Prospective Pioglitazone Clinical Trial in Macrovascular Events
PWV
: pulse wave velocity
QOF
: Quality and Outcomes Framework
RCT
: randomized clinical trial
RR
: relative risk
SBP
: systolic blood pressure
SCORE
: Systematic Coronary Risk Evaluation Project
SEARCH
: Study of the Effectiveness of Additional Reductions in Cholesterol and
SHEP
: Systolic Hypertension in the Elderly Program
STEMI
: ST-elevation myocardial infarction
SU.FOL.OM3
: SUpplementation with FOlate, vitamin B6 and B12 and/or OMega-3 fatty acids
Syst-Eur
: Systolic Hypertension in Europe
TNT
: Treating to New Targets
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use
VITATOPS
: VITAmins TO Prevent Stroke
VLDL
: very low-density lipoprotein
WHO
: World Health Organization

### 1.1 Introduction

Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously throughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has …

/pdf/european-guidelines-on-cardiovascular-disease-prevention-in-4z4nw4311i.pdf

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012)

2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular riskThe Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS)

Authors/Task Force Members: Franz-Josef Neumann* (ESC Chairperson) (Germany), Miguel Sousa-Uva* (EACTS Chairperson) (Portugal), Anders Ahlsson (Sweden), Fernando Alfonso (Spain), Adrian P. Banning (UK), Umberto Benedetto (UK), Robert A. Byrne (Germany), Jean-Philippe Collet (France), Volkmar Falk (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Canada), Adnan Kastrati (Germany), Akos Koller (Hungary), Steen D. Kristensen (Denmark), Josef Niebauer (Austria), Dimitrios J. Richter (Greece), Petar M. Seferovi c (Serbia), Dirk Sibbing (Germany), Giulio G. Stefanini (Italy), Stephan Windecker (Switzerland), Rashmi Yadav (UK), Michael O. Zembala (Poland) Document Reviewers: William Wijns (ESC Review Co-ordinator) (Ireland), David Glineur (EACTS Review Co-ordinator) (Canada), Victor Aboyans (France), Stephan Achenbach (Germany), Stefan Agewall (Norway), Felicita Andreotti (Italy), Emanuele Barbato (Italy), Andreas Baumbach (UK), James Brophy (Canada), Héctor Bueno (Spain), Patrick A. Calvert (UK), Davide Capodanno (Italy), Piroze M. Davierwala

/pdf/2014-esc-eacts-guidelines-on-myocardial-revascularization-3fr5n9jz36.pdf

2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).

https://air.unimi.it/bitstream/2434/689390/2/main.pdf

2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk

This is the second iteration of the European Society of Cardiology (ESC) and European Association for the Study of Diabetes (EASD) joining forces to write guidelines on the management of diabetes mellitus (DM), pre-diabetes, and cardiovascular disease (CVD), designed to assist clinicians and other healthcare workers to make evidence-based management decisions. The growing awareness of the strong biological relationship between DM and CVD rightly prompted these two large organizations to collaborate to generate guidelines relevant to their joint interests, the first of which were published in 2007. Some assert that too many guidelines are being produced but, in this burgeoning field, five years in the development of both basic and clinical science is a long time and major trials have reported in this period, making it necessary to update the previous Guidelines.

/pdf/2019-esc-guidelines-on-diabetes-pre-diabetes-and-4treq2fwvr.pdf

2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD

2D
: two-dimensional
3D
: three-dimensional
ABI
: ankle–brachial index
ACAS
: Asymptomatic Carotid Atherosclerosis Study
ACCF
: American College of Cardiology Foundation
ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndrome
ACST
: Asymptomatic Carotid Surgery Trial
ALI
: acute limb ischaemia
ASTRAL
: Angioplasty and Stenting for Renal Artery Lesions trial
BASIL
: Bypass versus Angioplasty in Severe Ischaemia of the Leg
BOA
: Dutch Bypass Oral Anticoagulants or Aspirin
CABG
: coronary artery bypass grafting
CAD
: coronary artery disease
CAPRIE
: Clopidogrel versus Aspirin in Patients at Risk for Ischaemic Events
CAPTURE
: Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events
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 Stabilization, Management and Avoidance
CI
: confidence interval
CLEVER
: Claudication: Exercise Versus Endoluminal Revascularization
CLI
: critical limb ischaemia
CORAL
: Cardiovascular Outcomes in Renal Atherosclerotic Lesions
COURAGE
: Clinical Outcomes Utilization Revascularization and Aggressive Drug Evaluation
CPG
: Committee for Practice Guidelines
CREST
: Carotid Revascularization Endarterectomy vs. Stenting Trial
CT
: 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
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EUROSCORE
: European System for Cardiac Operative Risk Evaluation
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

Guidelines 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 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. Guidelines are no substitutes but are complements for textbooks and cover the ESC Core Curriculum topics. Guidelines 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 Guidelines have been issued in recent years by the European Society of Cardiology (ESC) 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 ESC Guidelines can be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.

Members of this Task Force were selected by the ESC 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 ESC Committee for Practice Guidelines (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 . …

https://www.siapav.it/pdf/ESC%20Guidelines.pdf

ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC).

A moratorium on carotid artery stenting (CAS) has been recently proposed. Current randomised evidence supports the notion that carotid endarterectomy (CEA) is better than CAS. A meta-analysis of the randomised trials compared the two strategies and included data from the recent International Carotid Stenting Study (ICSS). This meta-analysis indicated that patients who received CAS had a signifi cant increased risk of 30-day death or stroke compared with patients who received CEA (odds ratio 1·60; 95% CI 1·26–2·02). As randomised clinical trials are the gold standard of clinical investigation, it seems unwise to challenge them. However, for the comparison of CAS versus CEA, most of the randomised trials should be considered not only scientifi cally but also ethically questionable because the endovascular experience required for interventionalists to be eligible for the studies was minimal (table). As a consequence, patients allocated to CAS might have been exposed to unnecessary risk and the assessment of safety and effi cacy of the endovascular approach confounded. In the French Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) study, a lifetime experience of at least 12 CAS interventions was required. Alternatively, a minimum of fi ve CAS procedures was deemed to be suffi cient if the interventionalist had a lifetime experience of at least 30 stenting procedures in supraaortic vessels. The rationale for this adjustment is diffi cult to understand given that subclavian and carotid interventions diff er substantially. For investigators who did not comply with these minimum requirements, the EVA-3S protocol allowed the procedure “under the supervision of an experienced tutor”, defi ned in the protocol as “a clinician who qualifi ed to perform stenting in this study”. In later correspondence, the investigators acknowledged that only 16% of the 265 patients treated with stenting were managed by operators who had done more than 50 CAS procedures in their lifetime and that 39% of patients were treated by physicians in training. Although such a track record can hardly be defi ned as good clinical practice or trial conduct, the information was not thought to be suffi ciently relevant to be reported in any of the EVA-3S publications. Concerns about CAS safety in the EVA-3S trial were raised after the enrolment of 80 patients in the endovascular arm. The safety committee recommended stopping the performance of CAS without the use of embolic protection devices, because the 30-day rate of stroke among patients undergoing un protected CAS was 26·7%, which was 3·9 times higher than that of patients treated with embolic protection (8·6%). However, in the clinical alert published by the EVA-3S investigators, the experience of the interventionalists was not questioned because “a learning eff ect is also unlikely to explain the diff erent complications rates, since protected CAS is a more complex technique than unprotected CAS”. This quote reveals a fundamental gap in understanding of the CAS procedure. In real-life practice, the use of embolic protection devices is widely embraced by experienced CAS interventionalists, whereas those with less expertise might be reluctant to use these devices. Additional evidence of the little endovascular experience among the investigators of EVA-3S is derived from the high rate of emergent conversion from CAS to CEA (5%). The fact that CAS was never reimbursed in France did not help the investigators to gain exposure to the procedure. According to the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study, a minimum of 25 successful consecutive CAS procedures was needed to participate as an investigator. However, a subsequent report revealed that, during the course of the trial, the protocol was amended to allow for tutoring of physicians who had only undertaken ten CAS procedures. Finally, in ICSS, a minimum of 50 total stenting procedures was required as long as at least ten of these involved the carotid artery. Tutor-assisted procedures were allowed for investigators with insuffi cient experience, again raising the concern of adequacy of training. The inexperience of the EVA-3S, SPACE, and ICSS investigators might have exposed the endovascular patients to an increased risk, not only because of insuffi cient operator skills, but also (and equally important) owing to inappropriate selection of patients. Interventions in patients with complex anatomy at the level of the aortic arch and supra-aortic vessels require more catheter manipulation than in patients with less tortuous or diseased vessels and place patients at increased risk of periprocedural stroke.

Carotid artery stenting versus surgery: adequate comparisons?

Guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de las enfermedades arteriales periféricas Documento sobre la enfermedad arteriosclerótica de las arterias extracraneales carótidas y vertebrales, mesentéricas, renales y de las extremidades inferiores y superiores Grupo de Trabajo de Diagnóstico y Tratamiento de las Enfermedades Arteriales Periféricas de la Sociedad Europea de Cardiología (ESC) Avalado por la Organización Europea de Accidentes Cerebrovasculares (European Stroke Organisation, ESO)

Marc van Sambeek

Papers

Carotid artery stenting versus surgery: adequate comparisons?