New cross-specialty guidelines on peripheral arterial diseases

New guidelines on peripheral arterial diseases (PADs) have been jointly published by the European Society of Cardiology (ESC) and European Society for Vascular Surgery (ESVS) (Aboyans et al, 2017). These guidelines mark the first time that ESC recommendations on PADs have been developed as a collaborative effort between cardiologists and vascular surgeons. Management of hypertension is achieved through a combination of medication regimen and lifestyle changes. However, the results of the studies examining the level of adherence among hypertensives indicated that the target was not achieved. Saarti et al (2015) found that the level of adherence for medication regimen is 29.1%.

What are PADs?

Over 40 million people in Europe are affected by PADs (Fowkes et al, 2013)—a term used to describe all arterial diseases except those affecting the coronary arteries and aorta. Peripheral arterial diseases include atherosclerotic disease of the extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries.

Multidisciplinary approach

The Task Force was led by ESC Chairperson, Professor Victor Aboyans, and ESVS Co-Chairperson, Professor Jean-Baptiste Ricco. Building on recommendations laid out in the 2011 ESC guidelines (Tendera et al, 2011), it was felt by both societies that a multidisciplinary approach for the management of patients was needed.

Collaboration between specialisms has meant that there is now a single European document on the management of patients with peripheral arterial diseases. Professor Aboyans said:

‘Working together has enabled us to be comprehensive in our recommendations.’

Speaking to theheart.org | Medscape Cardiology, Aboyans stressed the need for multidisciplinary management of patients with PADs. Given the different areas of the body affected by PADs, it is necessary that other specialties beyond cardiovascular medicine and surgery are involved. An example of this would be in the case of carotid disease.

Aboyans said:

‘Talking about the management of carotid disease, we also need the input of a neurologist; the same for nephrologists or gastroenterologists.

‘We cannot think any more about a patient at a consultation and the surgeon says: “Ok, I’ll operate on you, I’ll fix the problem, and then it’s over,” because this is just the beginning of another story, which is the long-term management and reassessment of these patients, as with coronary risk,’ he added.

Complications of PADs

According to Aboyans, patients suffering from PADs often have difficulty walking— particularly those with arterial disease of the extremities. This is owing to insufficient blood flow to the lower limbs brought on by stenoses or occlusions of the peripheral arteries. This can pose a complication, as many patients may be unaware that they have a more serious condition. This is because they do not suffer from common symptoms of circulatory problems, such as shortness of breath, due to being sedentary.

‘They may have heart failure, but they don’t really complain about shortness of breath, just because they don’t walk any more,’ he said.

The benefit of cross-specialty assessment is therefore apparent. This ensures that all possible areas for concern are taken into consideration.

‘It is really mandatory that, if a patient comes to one specialty, to also have the call with other specialties, and this complementary approach is of benefit to the patients,’ he said.

‘It is one thing to fix the local-territory issue, the other is the cardiovascular health of these patients and, in the end, the prognosis.’

Changes to the guidelines

In putting together these guidelines, a comprehensive review of the published evidence was carried out. The Task Force was made up of experts in the field selected by the ESC. It included representation from the ESVS and European Stroke Organisation (ESO). This ensured all professionals responsible for the medical care of patients with this pathology were involved. The Task Force considered published articles on management of a given condition according to the ESC Committee for Practice Guidelines policy. These were then approved by the ESVS and ESO. A critical evaluation of diagnostic and therapeutic procedures for PADs was carried out, including an assessment of the risk– benefit ratio.

A number of changes have been made since the 2011 guidelines were published and new recommendations set out for the management of PADs. A chapter devoted to the use of antithrombotic drugs has been introduced for the first time. There is also a new chapter on the management of other cardiac conditions frequently encountered in patients with PADs. These include heart failure, atrial fibrillation and valvular heart disease. The chapter on mesenteric artery disease has been entirely revisited. Ricco said:

‘We have updated this chapter with new data showing the interest of endovascular surgery in these often frail patients.’

The Task Force has recommended revascularisation of asymptomatic carotid stenosis only in patients at high risk of stroke. This is despite no new major trials on the management of asymptomatic carotid artery disease since the last guidelines were published. However, there are new data on the long-term risk of stroke in patients with asymptomatic carotid stenosis.

‘The previous guidelines recommended revascularisation for all patients with asymptomatic carotid stenosis, so this is an important change,’ said Aboyans.

‘Trials showing the benefits of revascularisation compared to best medical therapy alone were performed in the 1990s but stroke rates in all patients with asymptomatic carotid stenosis have decreased since then— regardless of the type of treatment— so the applicability of those trial results in the current management of these patients is more questionable.’

There is now a strong recommendation against systematic revascularisation of renal stenosis in patients with renal artery disease. This is following the publication of several trials.

WIfI classification

A new classification system (WIfI) has been proposed as the initial assessment of all patients with ischaemic rest pain or wounds. The system takes into account the three main factors that contribute to the risk of limb amputation, which are:

• Wound
• Ischaemia
• foot Infection.

Professor Ricco emphasised the impor¬tance of the new WIfI classification in lower extremity artery disease.

Guidelines into practice

The new guidelines encourage health professionals to consider its recommendations when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, they make clear that they do not override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition. This should be done in consultation with that patient or the patient’s caregiver where appropriate and/or necessary.

References

Aboyans V, Ricco JB, Bartelink MEL 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 extrem¬ity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017; [Epub ahead of print]. https://doi.org/10.1093/eurheartj/ehx095

Fowkes FG, Rudan D, Rudan I et al. Comparison of global estimates of prevalence and risk fac¬tors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–1340. https://doi.org/10.1016/S0140-6736(13)61249-0

Tendera M, Aboyans V, Bartelink ML et al. 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). Eur Heart J. 2011;32(22):2851–2906. https://doi.org/10.1093/eurheartj/ehr211

Taken from British Journal of Cardiac Nursing, published November 2017.