ESC updates Guidelines for peripheral artery disease

European Society of Cardiology (ESC) Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, developed in collaboration with the European Society for Vascular Surgery (ESVS), are published online today in European Heart Journal, European Journal of Vascular and Endovascular Surgery, and the ESC website.

More than 40 million Europeans are affected by peripheral arterial diseases, with increased risk of stroke, disability, heart attack and death. Peripheral arterial diseases include atherosclerotic disease of the extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries – in other words, all arterial diseases except the coronary arteries and aorta. They include lower extremity artery disease, which is often referred to as peripheral artery disease.

This is the first time that ESC recommendations on peripheral arterial diseases have been developed as a collaborative effort between cardiologists and vascular surgeons. The Task Force was led by Prof Victor Aboyans (ESC Chairperson) and Prof Jean-Baptiste Ricco (ESVS Co-Chairperson).

Prof Aboyans said: "We now have a single European document on the management of patients with peripheral arterial diseases. Working together has enabled us to be comprehensive in our recommendations."

For the first time there is a single chapter devoted to the use of antithrombotic drugs. This is a hot topic and advice is given for each location of peripheral arterial disease regarding the use of antiplatelet and anticoagulant therapies.

Also new is a chapter on the management of other cardiac conditions frequently encountered in patients with peripheral arterial diseases, such as heart failure, atrial fibrillation, and valvular heart disease. "Patients with peripheral arterial diseases often have other cardiac conditions and while there is not much specific evidence on how to manage these we have produced recommendations, mostly based on expert opinion," said Prof Aboyans.

While there have been no new major trials on the management of asymptomatic carotid artery disease since the 2011 Guidelines, there have been new data on the long-term risk of stroke in patients with asymptomatic carotid stenosis. The Task Force now recommends revascularisation of asymptomatic carotid stenosis only in patients at high risk of stroke.

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

In patients with renal artery disease, there is now a strong recommendation against systematic revascularisation of renal stenosis following the publication of several trials. The 2011 Guidelines stated that stenting could be considered in patients with renal stenosis due to atherosclerotic disease.

The chapter on mesenteric artery disease has been entirely revisited. Prof Ricco said: "We have updated this chapter with new data showing the interest of endovascular surgery in these often frail patients."

In lower extremity artery disease, Professor Ricco emphasised the importance of the new WIfI classification that has been introduced for risk stratification of patients with chronic limb threatening ischaemia. The system takes into account the three main factors that contribute to the risk of limb amputation, which are wound (W), ischaemia (I), and foot infection (fI).

The Guidelines are accompanied by a companion question and answer document which outlines how to manage patients with different presentations of peripheral arterial diseases. It is also published online today in European Heart Journal.