Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from 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 for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents 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 development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 .

View this table:

 Table 1 
Classes of recommendations



View this table:

 Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the …

/pdf/guidelines-for-the-diagnosis-and-treatment-of-non-st-segment-4i7khpy8cj.pdf

Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes

K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.

https://www.kidney-international.org/article/S0085-2538(15)55105-3/pdf

Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

‘Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology’ recently published in European Heart Journal 1 rightly dedicates space to the pitfalls that can be encountered when reading presentation ECGs. However, we wish to draw attention to what we think is an important omission. No reference is made in this context to acute aortic syndrome (AAS)—a condition in …

/pdf/guidelines-for-the-diagnosis-and-treatment-of-non-st-segment-1nh3raym6e.pdf

Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology

ContextTotal cholesterol level is inversely associated with mortality in dialysis
patients, a group at high risk of cardiovascular disease (CVD). This paradox
may be explained by systemic inflammation and/or malnutrition, which are associated
with lower cholesterol levels and higher mortality.ObjectiveTo determine the relationship between cholesterol level and outcome
in patients undergoing dialysis, accounting for inflammation and malnutrition.Design, Setting, and ParticipantsProspective study of 823 patients enrolled from October 1995 to June
1998 who recently initiated dialysis, from 79 clinics, classified by absence
or presence of inflammation and/or malnutrition (defined as serum albumin
levels <3.6 mg/dL, C-reactive protein ≥10 mg/L, or interleukin 6 ≥3.09
pg/mL).Main Outcome MeasuresAll-cause and cardiovascular disease mortality.ResultsDuring a median follow-up of 2.4 years, 324 deaths (159 CVD deaths),
153 renal transplantations, and 10 losses to follow-up occurred. Average serum
cholesterol level was lower in the presence of inflammation/malnutrition than
in its absence. In a Cox model adjusted for age, race, and sex, a 40-mg/dL
(1.0-mmol/L) increment in baseline total serum cholesterol level was associated
with a decreased risk of all-cause mortality overall (relative hazard [RH],
0.92; 95% confidence interval [CI], 0.87-0.98) and in the presence of inflammation/malnutrition
(RH, 0.89; CI, 0.84-0.95). In contrast, serum cholesterol level was associated
with an increased risk in the absence of inflammation/malnutrition (RH, 1.32;
95% CI, 1.07-1.63). For CVD mortality, an inverse trend was not statistically
significant in the presence of inflammation/malnutrition, and a positive association
was evident in the absence of inflammation/malnutrition (RH, 1.41; 95% CI,
1.04-1.89). Further adjustment for traditional CVD risk factors, dialysis
modality, comorbidity, and inflammatory markers attenuated the inverse association
but strengthened the positive association.ConclusionsThe inverse association of total cholesterol level with mortality in
dialysis patients is likely due to the cholesterol-lowering effect of systemic
inflammation and malnutrition, not to a protective effect of high cholesterol
concentrations. These findings support treatment of hypercholesterolemia in
this population.

https://jamanetwork.com/journals/jama/articlepdf/198091/JOC31612.pdf

Association between cholesterol level and mortality in dialysis patients: role of inflammation and malnutrition

Context Cardiac troponin T (cTnT) and C-reactive protein (CRP) are prognostic markers in acute coronary syndromes. However, for patients with end-stage renal disease (ESRD) the ability of combinations of these markers to predict outcomes, and their association with cardiac pathology, are unclear. Objective To investigate the association between levels of cTnT and CRP and longterm risk of cardiac pathology and death in patients with ESRD. Design, Setting, and Participants A prospective cohort study initiated February through June 1998 and enrolling 224 patients with ESRD from 5 hemodialysis centers in the Houston-Galveston region of Texas. Levels of cTnT and CRP were analyzed at study entry in patients without ischemic symptoms. MainOutcomeMeasures All-causemortalityduringameanfollow-upof827(range, 29-1327) days. Secondary outcomes in predefined substudies were coronary artery disease (CAD), decreased (40%) left ventricular ejection fraction (LVEF), and presence of left ventricular hypertrophy (LVH). Results One hundred seventeen (52%) patients died during follow-up. For levels of cTnT and CRP, progressively higher levels predicted increased risk of death compared with the lowest quartile (for cTnT quartile 2: unadjusted hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.2-4.1; quartile 3: HR, 2.7; 95% CI, 1.5-4.9; quartile 4: HR, 3.0; 95% CI, 1.6-5.3. For CRP quartile 2: HR, 0.9; 95% CI, 0.5-1.6; quartile 3: HR, 1.8; 95% CI, 1.1-3.1; quartile 4: HR, 1.8; 95% CI, 1.1-3.2). Both cTnT and CRP remained independent predictors of death after adjusting for a number of potential confounders. The combination of cTnT and CRP results provided prognostic information when patients were divided into groups at or above and below the biomarker medians (high cTnT/high CRP levels vs low cTnT/low CRP levels for risk of death: HR, 2.5; 95% CI, 1.5-4.0). Elevated levels of cTnT, but not CRP, were strongly associated with diffuse CAD (n=67; 0%, 25%, 50%, and 62% prevalence of multivessel CAD across progressive cTnT quartiles, P.001). An LVEF of 40% or less was identified in 4 (9%), 3 (8%), 10 (27%), and 7 (19%) of patients across cTnT quartiles (P=.07). No trend for cTnT levels was found among patients with LVH (P=.45); similarly, no trend for CRP was found among patients with LVH (P=.65) or an LVEF of 40% or less (P=.75). Conclusions Among stable patients with ESRD, increasing levels of cTnT and CRP are associated with increased risk of death. Furthermore, higher levels of cTnT may identify patients with severe angiographic coronary disease.

https://jamanetwork.com/journals/jama/articlepdf/196953/joc30384.pdf

Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis.

N-Terminal pro brain natriuretic peptide (NT-proBNP) predicts left ventricular function and mortality in hemodialysis patients but not cardiac death: a two-year outcome study

Mathew M. Smiley

Papers

Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis.

N-Terminal pro brain natriuretic peptide (NT-proBNP) predicts left ventricular function and mortality in hemodialysis patients but not cardiac death: a two-year outcome study