指南2011accf-ase_h

1、2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesThom W. Rooke, Alan T. Hirsch, Sanjay Misr

2、a, Anton N. Sidawy, Joshua A. Beckman, Laura K. Findeiss, Jafar Golzarian, Heather L. Gornik, Jonathan L. Halperin, Michael R. Jaff, Gregory L. Moneta, Jeffrey W. Olin, James C. Stanley, Christopher J. White, John V. White and R. Eugene ZierlerCirculation published online September 29, 2011Circulati

3、on is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514Copyright 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539The online version of this article, along with updated information and services, is located on the W

4、orld Wide Web at: /content/early/2011/09/29/CIR.0b013e31822e80c3.citationData Supplement (unedited) at: /content/suppl/2011/09/29/CIR.0b013e31822e80c3.DC1.htmlDownloaded from / by guest on October 19, 2011Subscriptions: In

5、formation about subscribing to Circulation is online at /subscriptions/Permissions: Permissions & Rights Desk, Lippincott Williams & Wilk, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail:j

6、Reprints: Information about reprints can be found online at /reprints ACCF/AHA Focused Update2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline)A Report of the American Coll

7、ege of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesDeveloped in Collaboration With the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery2011 WRITING GROU

8、P MEMBERS*Thom W. Rooke, MD, FACC, Chair; Alan T. Hirsch, MD, FACC, Vice Chair*; Sanjay Misra, MD, Vice Chair*; Anton N. Sidawy, MD, MPH, FACS, Vice Chair;Joshua A. Beckman, MD, FACC, FAHA* ; Laura K. Findeiss, MD; Jafar Golzarian, MD; Heather L. Gornik, MD, FACC, FAHA*; Jonathan L. Halperin, MD, FA

9、CC, FAHA*; Michael R. Jaff, DO, FACC*; Gregory L. Moneta, MD, FACS;Jeffrey W. Olin, DO, FACC, FAHA*#; James C. Stanley, MD, FACS; Christopher J. White, MD, FACC, FAHA, FSCAI*;John V. White, MD, FACS; R. Eugene Zierler, MD, FACS2005 WRITING COMMITTEE MEMBERSAlan T. Hirsch, MD, FACC, Chair; Ziv J. Has

10、kal, MD, FAHA, FSIR, Co-Chair; Norman R. Hertzer, MD, FACS, Co-Chair; Curtis W. Bakal, MD, MPH, FAHA; Mark A. Creager, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA;Loren F. Hiratzka, MD, FACC, FAHA, FACS; William R.C. Murphy, MD, FACC, FACS; Jeffrey W. Olin, DO, FACC; Jules B. Puschett, MD,

11、FAHA; Kenneth A. Rosenfield, MD, FACC; David Sacks, MD, FSIR; James C. Stanley, MD, FACS; Lloyd M. Taylor, Jr, MD, FACS; Christopher J. White, MD, FACC, FAHA, FSCAI*;John V. White, MD, FACS; Rodney A. White, MD, FACS*Writing group members are required to recuse themselves from voting on sections to

12、which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. ACCF/AHA Representative. Society of Interventional Radiology Representative. Society for Vascular Surgery Representative. Society for Vascular Medicine Representative. ACCF/AHA Task

13、 Force on Practice Guidelines Li aison. #ACCF/AHA Task Force on Performance Measures Liaison. *Society for Cardiovascular Angiography and Interventions Representative.This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Scie

14、nce Advisory and Coordinating Committee in July 2011.The American Heart Association requests that this document be cited as follows: Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zie

15、rler RE. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:.This arti

16、cle is copublished in the Journal of the American College of Cardiology, Catheterization and Cardiovascular Interventions, the Journal of Vascular Surgery, and Vascular Medicine.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (

17、) and the American Heart Association (). A copy of the document is available at /statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail kelle ramsaywolterskluwer.

18、com.Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guideline development, visit /statements and select the “Policies and Development” link.Permissions: Multiple copies, modification, alteration, enhanc

19、ement, and/or distribution of this document are not permitted without the expresspermission of the American Heart Association.tructions for obtaining permission are located at /HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permis

20、sions Request Form” appears on the right side of the page.(Circulation. 2011;124:00-00.) 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc.Circulation is available at DOI: 10.1161/CIR.0b013e31822e80c3Downloaded from http:/circ.aha

21、/ by guest on October 19, 20112CirculationNovember 1, 2011ACCF/AHA TASK FORCE MEMBERSAlice K. Jacobs, MD, FACC, FAHA, Chair; Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect; Nancy Albert, PhD, CCNS, CCRN, FAHA; Mark A. Creager, MD, FACC, FAHA;Steven M. Ettinger, MD, FACC; Robert A. Guy

22、ton, MD, FACC;Jonathan L. Halperin, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; E. Magnus Ohman, MD, FACC; William Stevenson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHATable of ContentsPreamble000the ACCF and AHA have developed during their partnershi

23、p of 20 years.These updated guideline recommendations reflect a con- sensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as being important to the relevant patient population, as well as other new data deemed to

24、 have an impact on patient care (see Section 1.1, Methodology and Evidence Review, for details). This focused update is not intended to represent an update based on a complete literature review from the date of the previous guideline publication. Specific criteria/considerations for inclusion of new

25、 data include the following:1.Introduction0001.1. Methodology and Evidence Review0001.2. Organization of the Writing Group0001.3. Document Review and Approval0001.4. Scope of the Focused Update000Lower Extremity PAD0002.5. Diagnostic Methods0002.5.1. Recommendations for Ankle-Brachial Index, Toe-Bra

26、chial Index, andSegmental Pressure Examination0002.6. Treatment000. Recommendations for Smoking Cessation000. Recommendations for Antiplatelet andAntithrombotic Drugs0002.6.3. Recommendations for Critical Limb Ischemia: Endovascular and Open Surgical Treatment for LimbSalvage000Aneurys

27、m of the Abdominal Aorta, Its BranchVessels, and the Lower Extremities000. Recommendations forManagement Overview0002.publication in a peer-reviewed journal;large, randomized, placebo-controlled trial(s); nonrandomized data deemed important on the basis of results affecting current safety and

28、 efficacy assumptions, including observational studies and meta-analyses; strength/weakness of research methodology and findings; likelihood of additional studies influencing current findings;impact on current and/or likelihood of need to develop new performance measure(s);request(s) and requirement

29、(s) for review and update from the practice community, key stakeholders, and other sources free of relationships with industry or other potential bias;number of previous trials showing consistent results; and need for consistency with a new guideline or guideline updates or revisions.5.References000

30、Appendix 1. Author Relationships With Industry andOther Entities (Relevant)000Appendix 2. Reviewer Relationships With IndustryAnd Other Entities (Relevant)000Appendix 3. 2011 Peripheral Artery Disease FocusedUpdate Summary Table000Selected members of the previous writing committee as well as other e

31、xperts in the subject under consideration are chosen by the ACCF and AHA to examine subject-specific data and to write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing group members review the selected late-breaking clinical trials and oth

32、er new data that have been vetted through the Task Force; weigh the strength of evidence for or agat particular tests, treatments, or procedures; and include esti- mates of expected outcomes where such data exist. Patient- specific modifiers, comorbidities, and issues of patient pref- erence that ma

33、y influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein. In analyzing the data and developing recommendations and supporting te

34、xt, the writing group uses evidence-based meth- odologies developed by the Task Force.1 The Class ofPreambleKeeping pace with the stream of new data and evolving evidence on which guideline recommendations are based is an ongoing challenge to timely development of clinical practice guidelines. In an

35、 effort to respond promptly to new evidence, the American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) Task Force on Practice Guidelines (Task Force) has created a “focused update” process to revise the existing guideline recommen- dations that are affected by the evolving

36、 data or opinion. New evidence is reviewed in an ongoing fashion to more effi- ciently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence is reviewed at least twice a year, and updates are initiated on an as-needed basis

37、 and completed as quickly as possible while maintaining the rigorous methodology thatDownloaded from / by guest on October 19, 2011Rooke et al2011 PAD Guideline Focused Update3Table 1.Applying Classification of Recommendations and Level of EvidenceA recommendation with Leve

38、l of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is

39、useful or effective.*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.For comparative effectiveness recommendatio

40、ns (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in additi

41、on to evidence and/or agreement that a given treatment orrecommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommenda- tions at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if availabl

42、e. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing group is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recomm

43、endations within each COR. A new addition to this methodology is a separation of the Class III recommendations to delineate whether the recommenda-procedure is or is not useful/effective orome situationsmay cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the t

44、reatment effect. The writing group reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospec- tive, prospective, or randomized where

45、 appropriate. For certain conditions for which inadequate data are available,Downloaded from / by guest on October 19, 20114CirculationNovember 1, 2011tion is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasin

46、g number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only. In view of the advances in medical therapy across the sp

47、ectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I). This new term, GDMT, will be used herein andthroughout all future guide

48、lines.Because the ACCF/AHA practice guidelines address pa- tient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside Nort

49、h America, each writing group reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are

50、intended to assist healthcare providers in clinical decision making by describ- ing a range of generally acceptable approaches to the diag- nosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most ci

51、rcumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guide- lines may be appropriate. Clinical decis

52、ion making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise i

53、n which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate. Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding

54、 and adherence may adversely affect out- comes, physicians and other healthcare providers should make every effort to engage the patients active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to aentities

55、 (RWI) that requires the writing group chair plus a minimum of 50% of the writing group to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of rele- vance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing group and

56、 are updated as changes occur. All guideline recommendations require a confidential vote by the writing group and must be approved by a consensus of the voting members. Members are not permitted to write, and must recuse themselves from voting on, any recommendation or section to which their RWI app

57、ly. Members who recused themselves from voting are indicated in the list of writing group members, and section recusals are noted in Appendix1. Authors and peer reviewers RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency,

58、 writing group members comprehensive disclosure informationincluding RWI not pertinent to this documentis available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at / ACC/About-ACC/Leadership/Guidelines-and-Documents- Task-Forces.aspx. The work of the writing group was sup- ported exclusively by the ACCF and AHA without commer- cial support. Writing group members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing phys