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 extremity 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)

Familial Hypercholesterolemia and Risk of Peripheral Arterial Disease and Chronic Kidney Disease

CONTEXT

Individuals with familial hypercholesterolemia (FH) have a high risk of coronary artery disease, but their risk of peripheral arterial disease (PAD) and chronic kidney disease (CKD) is unknown.

OBJECTIVE

In individuals with clinical FH, we tested the hypotheses (1) that the risks of PAD and CKD are elevated and (2) that low ankle-brachial index (ABI) and estimated glomerular filtration rate (eGFR) are associated with a high risk of myocardial infarction.

DESIGN AND SETTING

Prospective cohort study of the general population.

PARTICIPANTS

A total of 106,172 individuals, of whom 7109 were diagnosed with FH.

MAIN OUTCOME MEASURES

PAD, CKD, and myocardial infarction.

RESULTS

Compared with individuals with unlikely FH, multivariable adjusted ORs (95% CIs) of PAD were 1.84 (1.70 to 2.00) in those with possible FH and 1.36 (1.00 to 1.84) in individuals with probable/definite FH. For CKD, the corresponding ORs (95% CIs) were 1.92 (1.78 to 2.07) and 2.42 (1.86 to 3.26). Compared with individuals with unlikely FH and ABI >0.9, the multivariable adjusted hazard ratio (95% CI) of myocardial infarction was 4.60 (2.36 to 8.97) in those with possible/probable/definite FH and ABI ≤0.9. Compared with individuals with unlikely FH and eGFR ≥60 mL/min/1.73 m2, the corresponding value was 2.19 (1.71 to 2.82) in those with possible/probable/definite FH and eGFR <60 mL/min/1.73 m2.

CONCLUSIONS

Individuals with clinical FH have increased risks of PAD and CKD, and low ABI and eGFR are associated with high risk of myocardial infarction. Consequently, individuals with FH should be screened for PAD and CKD, and ABI and eGFR may be used as prognostic tools in the management and treatment of FH to identify those at very high risk of myocardial infarction.

Non-vitamin K antagonist oral anticoagulants in patients with an increased risk of bleeding

The non-vitamin K antagonist oral anticoagulants (NOACs) have considerably changed clinical practice and are increasingly being used as an alternative to vitamin K antagonists (VKAs) for 3 main reasons: 1) an improved benefit-risk ratio (in particular lower rates of intracranial bleeding), 2) a more predictable effect without the need for routine monitoring, and 3) fewer food and drug interactions compared with VKAs. Currently, there are four NOACs available: the factor Xa inhibitors apixaban, edoxaban, and rivaroxaban, and the thrombin inhibitor dabigatran. This consensus paper reviews the properties and usage of NOACs in a number of high-risk patient populations, such as patients with chronic kidney disease, patients ≥80 years of age and others and provides guidance for the use of NOACs in patients at risk of bleeding.

Long-term outcome of stenting for atherosclerotic renal artery stenosis and the effect of angiographic restenosis

BACKGROUND

Symptomatic renal artery stenosis (RAS) is mainly treated with pharmacological blood pressure control, sometimes with percutaneous transluminal renal angioplasty (PTRA). It is unclear if PTRA benefits these patients over time.

PURPOSE

To determine long-term renal function, morbidity, and mortality in patients with symptomatic RAS treated with PTRA, and whether long-term outcomes are associated with angiographic restenosis.

MATERIAL AND METHODS

Retrospective single-center, long-term follow-up of 57 patients with atherosclerotic RAS treated with PTRA with stent during 1995-2004 and investigated for restenosis with angiography after one year. Outcomes were retrieved from medical records and from mandatory healthcare registries. Mortality rates were related to expected survival in an age- and gender-matched population, using a life-table database. Surviving patients were assessed with blood pressures, laboratory tests, duplex ultrasonography, and radioisotope renography.

RESULTS

Median follow-up was 11 years 7 months. Major indications for PTRA were therapy-resistant hypertension and declining renal function. Angiographic restenosis at one year was found in 21 of 57 patients (37%). Thirty-six patients (60%) died during follow-up. Main cause of death was cardiovascular events (54%). Mortality was significantly increased, and morbidity and healthcare utilization were high. Hypertension control during follow-up was stable with persistent need for anti-hypertensive medication, and renal function remained moderately reduced with no long-term difference between patients with vs. without restenosis.

CONCLUSION

Long-term prognosis after PTRA for atherosclerotic RAS is dismal, with high mortality and morbidity and reduced renal function, despite maintained hypertension control. Restenosis does not appear to affect late outcome.

Mid- and long-term prognosis of off- vs. on-pump coronary artery bypass graft in patients with multisite artery disease

BACKGROUND

Among patients with coronary artery disease (CAD), around 25% have multisite artery disease (MSAD). Patients with CAD and MSAD are at higher risk of peri-operative and long-term cardiovascular events. Whether off-pump coronary bypass grafting (CABG) can improve their prognosis is unknown. We aimed to assess the benefits of off- vs. on-pump cardiac surgery in patients undergoing CABG, according to coexistence of extra-cardiac artery disease.

METHODS

Between April 1998 and September 2008, 1221 patients undergoing CABG without any other intervention were enrolled. Overall death and major cardiovascular events were recorded at 1-month and during long-term follow-up. A propensity score (PS), derived from all relevant variables (P<0.25) associated with on-pump as compared to off-pump CABG, and representing the likelihood for each individual patient to receive off-pump CABG, was calculated.

RESULTS

MSAD was observed in 279 patients (23%). Off-pump CABG was performed in 208 (17%) patients. The median follow-up was 7.6 years. The 10-year mortality was significantly lower in off- vs. on-pump CABG group (74±4% vs. 68±2%, P=0.024). In patients with MSAD, there was a trend for better survival for off- vs. on-pump CABG (63±8% vs. 50±4%, P=0.078). After adjustment for PS, we found no further difference between on- and off-pump CABG both in the whole cohort (HR=1.30, P=0.10), as well as in MSAD patients (HR=1.51, P=0.14).

CONCLUSIONS

Patients with MSAD receiving CABG are at worst prognostic than those with isolated CAD. In these patients, we found no significant difference in the long-term mortality and cardiovascular events between on- and off-pump CABG.

Urgent need to clarify the definition of chronic critical limb ischemia - a position paper from the European Society for Vascular Medicine

Chronic critical lower limb ischemia (CLI) has been defined as ischemia that endangers the leg. An attempt was made to give a precise definition of CLI, based on clinical and hemodynamic data (Second European Consensus). CLI may be easily defined from a clinical point of view as rest pain of the distal foot or gangrene or ulceration. It is probably useful to add leg ulcers of other origin which do not heal because of severe ischemia, and to consider the impact of frailty on adverse outcome. From a hemodynamic viewpoint there is no consensus and most of the existing classifications are not based upon evidence. We should thus propose a definition and then validate it in a prospective cohort in order to define the patients at major risk of amputation, and also to define the categories of patients whose prognosis is improved by revascularisation. From today's available data, it seems clear that the patients with a systolic toe pressure (STP) below 30 mmHg must be revascularised whenever possible. However other patients with clinically suspected CLI and STP above 30 mmHg must be evaluated and treated in specialised vascular units and revascularisation has to be discussed on a case by case basis, taking into account other data such as the WiFi classification for ulcers.In conclusion, many useful but at times contradictory definitions of CLI have been suggested. Only a few have taken into account evidence, and none have been validated prospectively. This paper aims to address this and to give notice that a CLI registry within Europe will be set up to prospectively validate, or not, the previous and suggested definitions of CLI.

Comparison of Outcomes and Cost of Endovascular Management Versus Surgical Bypass for the Management of Lower Extremities Peripheral Arterial Disease

The management of lower extremities peripheral arterial disease (LE-PAD) has always been debatable. We sought to explore in-hospital outcomes in hospitalizations that underwent endovascular or bypass surgery for LE-PAD from nation's largest, publicly available database. The National Inpatient Sample from 2012 to 2014 was queried to identify adult hospitalizations underwent endovascular management and bypass surgery for LE-PAD. Appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes were utilized to identify hospitalizations. A total of 89,256 hospitalizations were identified having endovascular management or bypass surgery for LE-PAD. More hospitalizations underwent endovascular intervention as compared with bypass surgery. Overall, hospitalizations for endovascular management had higher baseline co-morbidities and older age. A propensity score matched analysis was performed to compare in-hospital outcomes. After matching, 28,791 hospitalizations were included in each group. In-hospital mortality was significantly lower with endovascular intervention procedure as compared with surgical bypass group (1.5% vs 2.5%, p ≤0.001). All other secondary outcomes were noted lower with endovascular management except stroke and postprocedural infection. Taken together, these may account for higher discharges to home, lower length of stay, and less cost of hospitalizations associated with endovascular management. In conclusion, endovascular management is associated with lower in-hospital morbidity, mortality, length of stay, and cost when compared with bypass surgery in this study.

Drug-Coated Balloon Angioplasty Compared With Uncoated Balloons in the Treatment of 200 Chinese Patients With Severe Femoropopliteal Lesions: 24-Month Results of AcoArt I

OBJECTIVES

The authors sought to investigate the midterm efficacy and safety of drug-coated balloon (DCB) in the treatment of severe femoropopliteal artery disease (FPAD).

BACKGROUND

The midterm outcome of DCB versus uncoated balloon percutaneous transluminal angioplasty (PTA) for FPAD are still debated.

METHODS

A total of 200 Chinese patients with FPAD were prospectively randomized into treatment with DCB or with PTA. The primary efficacy endpoints were primary patency of the target lesion, freedom from clinically driven target lesion revascularization, improved ankle-brachial index, and improved Rutherford class at 24 months. The primary safety endpoint was the rate of major adverse events.

RESULTS

The DCB group and PTA group were comparable in demographic characteristics and clinical severity at baseline. At 24-month follow-up, primary patency was better in the DCB group versus PTA group (64.6% vs. 31.4%; p < 0.001). The DCB group had a higher rate of freedom from clinically driven target lesion revascularization than the PTA group (86.5% vs. 58.9%; p < 0.001). Rutherford class and ankle-brachial index also confirmed more improvements in the DCB group (p < 0.01 and p < 0.05, respectively). There was no significant difference in major adverse events.

CONCLUSIONS

The superiority of DCB versus PTA in the efficacy of FPAD treatment persists at 24-month follow-up and the safety of DCB is equivalent to that of PTA.

The intrinsic prognostic value of the ankle-brachial index is independent from its mode of calculation

The object of this study was to compare the prognostic value of different methods of ankle-brachial index (ABI) calculation. From April 1998 to September 2008, we calculated the ABI in 1223 patients before coronary artery bypass grafting. The ABI was calculated according to five different calculation modes of the numerator. The patients were classified into three groups: clinical peripheral artery disease (PAD), subclinical PAD if no clinical history but abnormal ABI (< 0.90 or > 1.40), and no PAD. The primary outcome was total mortality. During a follow-up of 7.6 years (0.1-15.9), 406 patients (33%) died. The prevalence of the subclinical PAD varied from 22% to 29% according to the different modes of ABI calculation. Areas under the ROC curve to predict mortality according to different calculation modes varied from 0.608 ± 0.020 to 0.625 ± 0.020 without significant differences. The optimal ABI threshold to predict mortality varied for every method, ranging from 0.87 to 0.95. In multivariate models, ABI was significantly and independently associated with total mortality (hazard ratio (HR) = 1.46, 95% CI: 1.15-1.85, p = 0.002); however, this association was not significantly different between the various methods (HRs varying from 1.46 to 1.67). The use of the optimal ABI threshold for each calculation mode (rather than standard 0.90) allowed a slight improvement of the model. In conclusion, the ABI prognostic value to predict mortality is independent from its method of calculation. The use of different optimal thresholds for each method enables a comparable prognosis value.

[Multimorbid vascular patients-do endovascular techniques expand the limits?]

The answer to the question of whether endovascular techniques extend the barriers to treatment in multimorbid vascular patients depends on the localization of the vascular disease and its stage. In multimorbid vascular patients with limited life expectancy and asymptomatic carotid stenosis, neither an endovascular nor an open procedure is indicated but a conservative best medicinal treatment is to be preferred. In symptomatic carotid stenosis the endovascular procedure is indicated for special anatomical conditions, such as contralateral carotid artery occlusion, contralateral recurrent nerve palsy, recurrent stenosis following endarterectomy, radical neck dissection and radiotherapy in the cervical region. In the treatment of intact abdominal aortic aneurysms (AAA), endovascular procedures reduce the perioperative risk especially in older patients, allowing the indications for intervention in this group of patients to be expanded, provided that the life expectancy of such treated patients is still several years. There is no clear evidence as to whether endovascular repair should be preferred in ruptured AAAs but there are indications that with the establishment of EVAR the proportion of patients receiving treatment has increased in those patients who were previously denied surgery after arrival in hospital. In critical limb ischemia the propagation of endovascular techniques has not so much extended the indications for invasive therapy but instead the endovascular approach has superseded open bypass surgery, which is positively reflected in a lower perioperative morbidity, especially in older frail patients.

Editor's Choice - Comparison of Outcomes After Open Surgical and Endovascular Lower Extremity Revascularisation Among End Stage Renal Disease Patients on Dialysis

OBJECTIVES

End stage renal disease (ESRD) patients with peripheral arterial disease (PAD) are at high risk of complications following open surgical revascularisation (OSR). Endovascular revascularisation (ER) is an option, but its role is unclear. This study sought to characterise the outcomes of ER and OSR in ESRD patients treated for claudication or critical limb ischaemia (CLI).

METHODS

The United States Renal Data System was used to investigate outcomes after lower extremity ER and OSR from 2005 to 2011. Primary outcomes were mortality, amputation, and peri-procedural myocardial infarction (MI). Kaplan-Meier (K-M) estimates were generated for mortality and amputation, logistic regression models for 30 day predictors, and proportional hazards models for long-term predictors.

RESULTS

A total of 20,347 patients underwent OSR and ER (20.3% OSR, 79.7% ER). CLI was the indication in 80.8% of ER and 88.4% of OSR. The unadjusted major amputation rate at 30 days was higher after ER compared with OSR (8.8% vs. 6.4%, p < .001). Conversely, the unadjusted mortality rate at 30 days was lower after ER compared with OSR (8.0% vs. 10.5%, p < .001). Multivariable logistic regression models adjusting for medical covariables and CLI versus claudication status demonstrated increased 30 day mortality risk with OSR compared with ER (OR 2.00, 95% CI 1.43-1.79, p < .001), MI (OR 1.38, 1.23-1.54, p < .001), and the combined endpoint of mortality and major amputation (OR 1.57, 1.16-2.12, p = .004), but lower odds of 30 day major amputation alone (OR 0.67, 0.58-0.77, p < .001). Proportional hazards models demonstrated increased long-term mortality risk with OSR compared with ER (HR 1.05, 1.00-1.09, p = .037), without a difference in major amputation (HR 0.99, 0.93-1.05, p = NS).

CONCLUSIONS

In this retrospective analysis of an administrative database, ESRD patients suffer from high mortality and amputation rates following lower extremity revascularisation. Compared with ER, OSR is associated with higher mortality. OSR has better 30 day limb salvage, although long-term outcomes are similar.

A polymer-coated, paclitaxel-eluting stent (Eluvia) versus a polymer-free, paclitaxel-coated stent (Zilver PTX) for endovascular femoropopliteal intervention (IMPERIAL): a randomised, non-inferiority trial

BACKGROUND

The clinical effect of a drug-eluting stent in the femoropopliteal segment has not been investigated in a randomised trial with a contemporary comparator. The IMPERIAL study sought to compare the safety and efficacy of the polymer-coated, paclitaxel-eluting Eluvia stent with the polymer-free, paclitaxel-coated Zilver PTX stent for treatment of femoropopliteal artery segment lesions.

METHODS

In this randomised, single-blind, non-inferiority study, patients with symptomatic lower-limb ischaemia manifesting as claudication (Rutherford category 2, 3, or 4) with atherosclerotic lesions in the native superficial femoral artery or proximal popliteal artery were enrolled at 65 centres in Austria, Belgium, Canada, Germany, Japan, New Zealand, and the USA. Patients were randomly assigned (2:1) with a site-specific, web-based randomisation schedule to receive treatment with Eluvia or Zilver PTX. All patients, site personnel, and investigators were masked to treatment assignment until all patients had completed 12 months of follow-up. The primary efficacy endpoint was primary patency (defined as a peak systolic velocity ratio ≤2·4, without clinically driven target lesion revascularisation or bypass of the target lesion) and the primary safety endpoint was major adverse events (ie, all causes of death through 1 month, major amputation of target limb through 12 months, and target lesion revascularisation through 12 months). We set a non-inferiority margin of -10% at 12 months. Primary non-inferiority analyses were done when the minimum sample size required for adequate statistical power had completed 12 months of follow-up. The primary safety non-inferiority analysis included all patients who had completed 12 months of follow-up or had a major adverse event through 12 months. This trial is registered with ClinicalTrials.gov, number NCT02574481.

FINDINGS

Between Dec 2, 2015, and Feb 15, 2017, 465 patients were randomly assigned to Eluvia (n=309) or to Zilver PTX (n=156). Non-inferiority was shown for both efficacy and safety endpoints at 12 months: primary patency was 86·8% (231/266) in the Eluvia group and 81·5% (106/130) in the Zilver PTX group (difference 5·3% [one-sided lower bound of 95% CI -0·66]; p<0·0001). 259 (94·9%) of 273 patients in the Eluvia group and 121 (91·0%) of 133 patients in the Zilver PTX group had not had a major adverse event at 12 months (difference 3·9% [one-sided lower bound of 95% CI -0·46]; p<0.0001). No deaths were reported in either group. One patient in the Eluvia group had a major amputation and 13 patients in each group required target lesion revascularisation.

INTERPRETATION

The Eluvia stent was non-inferior to the Zilver PTX stent in terms of primary patency and major adverse events at 12 months after treatment of patients for femoropopliteal peripheral artery disease.

FUNDING

Boston Scientific.

Cost-effectiveness of revascularization in patients with intermittent claudication

BACKGROUND

Revascularization is a treatment option for patients with intermittent claudication. However, there is a lack of evidence to support its long-term benefits and cost-effectiveness. The aim of this study was to compare the cost-effectiveness of revascularization and best medical therapy (BMT) with that of BMT alone.

METHODS

Data were used from the IRONIC (Invasive Revascularization Or Not in Intermittent Claudication) RCT where consecutive patients with mild-to-severe intermittent claudication owing to aortoiliac or femoropopliteal disease were allocated to either BMT alone (including a structured, non-supervised exercise programme) or to revascularization together with BMT. Inpatient and outpatient costs were obtained prospectively over 24 months of follow-up. Mean improvement in quality-adjusted life-years (QALYs) was calculated based on responses to the EuroQol Five Dimensions EQ-5D-3 L™ questionnaire. Cost-effectiveness was assessed as the cost per QALY gained.

RESULTS

A total of 158 patients were randomized, 79 to each group. The mean cost per patient in the BMT group was €1901, whereas it was €8280 in the group treated with revascularization in addition to BMT, with a cost difference of €6379 (95 per cent c.i. €4229 to 8728) per patient. Revascularization in addition to BMT resulted in a mean gain in QALYs of 0·16 (95 per cent c.i. 0·06 to 0·24) per patient, giving an incremental cost-effectiveness ratio of €42 881 per QALY.

CONCLUSION

The costs associated with revascularization together with BMT in patients with intermittent claudication were about four times higher than those of BMT alone. The incremental cost-effectiveness ratio of revascularization was within the accepted threshold for public willingness to pay according to the Swedish National Guidelines, but exceeded that of the UK National Institute for Health and Care Excellence guidelines.

[Lower extremity arteriopathy disease in the elderly: A systematic review]

Lower Extremity Arteriopathy Disease in the elderly is frequent with an ongoing increase of it prevalence and incidence mainly due to diabetes, hypertension and aging of the population. Despite improvement of revascularization therapy, outcome in this population is poor affected by frailty of elderly patient. Aging is associated with a higher prevalence of below the knee disease and wound, often with diagnostic delay leading to a major rate of amputation, mortality and alteration of quality of life. Moreover, it leads to an important health cost for society. This review aims to describe main features of LEAD in the elderly, providing keys for early recognition and managing of such disease in this population.

Lower extremity arterial disease in patients with diabetes: a contemporary narrative review

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

Oral antiplatelet agents in cardiovascular disease

Antiplatelet agents significantly reduce mortality and morbidity in ischemic heart disease, cerebrovascular disease and peripheral artery disease (PAD), and are therefore part of guideline-driven daily medical treatment in these patients. Due to its beneficial effects in the secondary prevention of atherothrombotic events, aspirin remains the most frequently prescribed antiplatelet agent in cardiovascular disease. In patients with acute coronary syndromes (ACS) and in those undergoing angioplasty with stent implantation dual antiplatelet therapy with aspirin and an adenosine diphosphate (ADP) receptor antagonist is indicated. The development of the newer ADP P2Y₁₂ inhibitors prasugrel and ticagrelor has further improved prognosis in ACS patients compared to clopidogrel. Moreover, vorapaxar allows the inhibition of platelet activation by thrombin via protease-activated receptor-1 and has been approved for the use in patients with PAD and in those with a history of myocardial infarction. This review article summarizes the current evidence on oral antiplatelet agents in cardiovascular disease. Keywords: Aspirin, clopidogrel, prasugrel, ticagrelor, vorapaxar, cardiovascular disease.

Different Vascular Responses to a Bare Nitinol Stent in Porcine Femoral and Femoropopliteal Arteries

Nitinol stents are widely used for the treatment of peripheral arterial diseases in lower extremity arteries and have shown different clinical outcomes depending on implanted arterial segments. We aimed to compare histopathological responses to nitinol stents in femoral artery (FA) with those in femoropopliteal artery (FPA), which is markedly bended during knee flexion. A single nitinol stent was implanted in FA and FPA of 21 domestic swine. The stented vessels were angiographically assessed and then harvested for histopathology at 1 and 3 months after implantation. Angiographic late lumen loss was significantly greater in FPA than in FA at 3 months. Neointimal area decreased in FA and increased in FPA from 1 to 3 months. Compared with FA, peri-strut area of FPA showed more pronounced hemorrhage and fibrin deposition at 1 month and angiogenesis and inflammation at 1 and 3 months. Injury to internal elastic lamina or media was minimal in both FA and FPA at both time points. In conclusion, vascular responses to nitinol stents were different between FA and FPA with respect to time course of neointimal formation and progress of healing, suggesting that repetitive interaction between stent and vessel wall during dynamic vessel motion affected vascular responses.

2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension

: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

Transradial Approach for Aortoiliac and Femoropopliteal Interventions: A Systematic Review and Meta-analysis

PURPOSE

To present a systematic review and meta-analysis comparing the transradial approach for aortoiliac and femoropopliteal interventions to the traditional transfemoral access.

METHODS

A search of the public domain databases MEDLINE, SCOPUS, Web of Science, and Cochrane Library Databases was performed to identify studies related to the use of the transradial approach for infra-aortic procedures. Meta-analysis was used to compare the transradial to the transfemoral route in terms of procedure success, complications, procedure parameters, and hospital length of stay. Results are presented as the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Nineteen studies containing 638 patients with transradial access for lower limb interventions were selected. Lesions were treated from the aortic bifurcation down to the popliteal artery. The mean technical success rate was 90.9%, conversion to a transfemoral approach was necessary in 9.9%, and complications were reported in 1.9%. The meta-analysis included 4 comparative studies involving 114 transradial and 208 transfemoral procedures. There was no significant advantage of either approach in terms of procedure success (OR 5.0, 95% CI 0.49 to 50.83, p=0.17), but the risk of developing a complication was significantly lower (OR 0.25, 95% CI 0.07 to 0.86, p=0.03) with the transradial approach.

CONCLUSION

Transradial access for lower limb endovascular interventions can be performed with comparable technical success and a lower overall complication profile compared to transfemoral access.

Antiplatelet therapy for peripheral artery disease

Atherosclerotic cardiovascular (CV) disease represents one of leading cause of mortality and morbidity in Western countries. An increased risk of CV events was identified in patients with peripheral arterial diseases (PADs), which include all arterial diseases, other than coronary arteries and the aorta. In particular, lower extremity artery disease (LEAD) and/or carotid artery disease present growing incidence in general population and a consequent increase in mortality and morbidity. Medical treatment, including antiplatelet therapy, is a cornerstone in management of these patients, even when they are treated with endovascular or surgical procedures. Despite their clinical relevance, data on optimal antiplatelet treatment in this clinical setting are lacking and often derived from clinical trials on coronary artery disease and by subgroups analysis. The purpose of this review is to examine the available data from registries, randomized trials and meta-analysis on antiplatelet treatment in patients with LEAD and carotid stenosis with the aim to provide evidence to support clinical decision making.

Rationale and methods of the IDOMENEO health outcomes of the peripheral arterial disease revascularisation study in the GermanVasc registry

Abstract. Background: Atherosclerotic disease of the lower extremity arteries (PAD) remains a significant burden on global healthcare systems with increasing prevalence. Various guidelines on the diagnosis and treatment of patients with PAD are available but they often lack a sufficient evidence base for high-grade recommendations since randomized and controlled trials (RCT) remain rare or are frequently subject to conflicts of interest. This registry trial aims to evaluate the outcomes of catheter-based endovascular revascularisations vs. open-surgical endarterectomy vs. bypass surgery for symptomatic PAD on medical and patient-reported outcomes. Methods and design: The study is a prospective non-randomized multicentre registry trial including invasive revascularisations performed in 10 000 patients treated for symptomatic PAD at 30 to 40 German vascular centres. All patients matching the inclusion criteria are consecutively included for a recruitment period of six months (between May and December 2018) or until 10 000 patients have been included in the study registry. There are three follow-up measures at three, six, and 12 months. Automated completeness and plausibility checks as well as independent site visit monitoring will be performed to assure high internal and external validity of the study data. Study endpoints include relevant major cardiovascular and limb events and patient-reported outcomes from two Delphi studies with experts in vascular medicine and registry-based research. Discussion: It remains unclear if results from RCT can reflect daily treatment practice. Furthermore, great costs and complexity make it challenging to accomplish high quality randomized trials in PAD treatment. Prospective registry-based studies to collect real-world evidence can help to overcome these limitations.

Summary of 2017 ESC guidelines on valvular heart disease, peripheral artery disease, STEMI and on dual antiplatelet therapy

During the ESC congress in September 2017 in Barcelona, the new ESC guidelines were presented and are now available on the ESC website. The new guidelines cover management recommendations on following cardiovascular items: valvular heart disease, peripheral artery disease, ST elevation myocardial infarction (STEMI) and on dual antiplatelet therapy. The present document gives a summary of these guidelines and highlights the most important recommendations and changes in the management of these diseases. It will help to increase awareness about the new guidelines and may stimulate to consult the full document for specific items. Ultimately, the authors hope that this document will enhance implementation of new ESC guidelines in daily clinical practice.

Indicators of outcome quality in peripheral arterial disease revascularisations – a Delphi expert consensus

Abstract. Introduction: Peripheral arterial disease (PAD) affects a continuously increasing number of people worldwide leading to more invasive treatments. Indication to perform invasive revascularisations usually arises from consensus-based recommendations of practice guidelines and from few randomized controlled trials where outcome measures focus mainly on risk factors associated with mortality and morbidity. To date, no broad consensual agreement of experts on valid indicators of outcome quality exists for PAD. Methods: A literature review was conducted to collect indicators of outcome quality from studies of PAD. The Delphi technique was used to achieve a consensual agreement on a set of core indicators. The expert panel of the two-round Delphi approach was formed by leading vascular specialists joining the IDOMENEO study, physician assistants, wound nurses, and patient representatives. Items were scored via a web-based anonymised electronic questionnaire using a five-point Likert-scale. Results: Out of 40 invited experts 30 joined the panel and completed round one. Twenty-four experts completed the second and final round. Forty-three indicators of outcome quality were initially identified and validated by the panel. After two Delphi rounds, 12 indicators (27.9 %) achieved the limit of agreement for relevance and four (9.3 %) for practicability. Major adverse limb events (MALE), major amputation, and major re-intervention (or re-operation) were consented as both highly relevant and practicable. Additionally, major adverse cardiovascular events (MACE), myocardial infarction, stroke or transient ischaemic attack, all-cause death, all re-intervention (or re-operation), wound infection, vascular access-related major complication, walking distance, and Rutherford-classification were consented as highly relevant. Ankle-brachial-index was consented as highly practicable. Conclusions: This Delphi approach of vascular experts identified three indicators as highly relevant and clinically practicable to be recommended as indicators of outcome quality in invasive PAD treatment. Among others, these consented items may help in harmonising future studies and quality benchmarking increasing their comparability, validity, and efficiency.

Risk-Benefit Assessment of Carotid Revascularization

Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Nitinol Self-Expanding Stents for the Treatment of Obstructive Superficial Femoral Artery Disease: Three-Year Results of the RELIABLE Japanese Multicenter Study

Objective: To assess the use of a nitinol stent to treat symptomatic stenoses or occlusions of the native superficial femoral artery (SFA).

Materials and Methods: Seventy-four patients were treated at 12 Japanese sites. The primary endpoint, freedom from target-limb failure (TLF), was a composite of device- or procedure-related death, target-limb amputation, target-vessel revascularization (TVR), or restenosis compared to an objective performance goal (OPG) at 12 months. Secondary endpoints, including primary patency, freedom from TVR/target-lesion revascularization (TLR), improvements in clinical parameters, and major adverse events (MAEs) were evaluated through 36 months.

Results: The mean overall lesion length was 80.7±38.9 mm (mean stented length: 98.8±46.1 mm). Freedom from TLF was 81.2% (p<0.001 compared to OPG) with a Kaplan–Meier estimate of 84.2% [95% confidence interval (95%CI) 73.3%, 90.9%] at 12 months. Primary patency was 71.0% at 12 months and 67.8% at 36 months. A total of 94.7% of patients improved by at least one Rutherford category and 70.2% of patients improved ankle–brachial indices ≧0.10 from baseline to 36 months. Freedom from TVR/TLR (Kaplan–Meier) was 90% at 12 months and 79.5% at 36 months. Four MAEs were reported; none were found to be device or procedure related.

Conclusion: A self-expanding stent was used safely to treat stenotic and occlusive lesions of the SFA in a Japanese patient population. The composite endpoint, freedom from TLF, was superior to an historical control at one year, with low rates of revascularization and good functional and clinical outcomes through three years.

Long-Term Results of Femorotibial Polytetrafluoroethylene Bypass with a Distal Vein Cuff for Critical Limb Ischemia

Objective: Although autologous veins are the first-choice conduit for femorotibial artery bypass, if there are no appropriate autologous veins, we perform femorotibial artery bypass using polytetrafluoroethylene (PTFE) with a distal vein cuff for patients with critical limb ischemia (CLI). This study examined the long-term outcomes of femorotibial artery bypass using PTFE with a Miller's cuff. Materials and Methods: Using prospectively collected data for 444 distal bypasses, a retrospective analysis was conducted for 32 femorotibial PTFE bypasses with a Miller's cuff (PTFE-Miller's cuff) performed for patients with CLI from April 1994 to December 2016. Results: Primary and secondary patency rates of PTFE-Miller's cuff at 3 years were 35.8% and 51.2%, respectively. Limb salvage rate of PTFE-Miller's cuff at 3 years was 71.0%. Conclusion: Although the patency rate was low and failed to yield satisfactory results, the limb salvage rate remained relatively high. Femorotibial PTFE bypass with a Miller's cuff was a useful technique of limb salvage for patients with CLI in whom an appropriate autologous vein could not be used.

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

PURPOSE OF REVIEW

Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.

RECENT FINDINGS

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise. 'Average surgical risk' patients with an asymptomatic carotid artery stenosis of 60-99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed 'high risk' for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

Antithrombotic treatment is associated with intraplaque haemorrhage in the atherosclerotic carotid artery: a cross-sectional analysis of The Rotterdam Study

Aims

Antithrombotic treatment plays a key role in stroke prevention, but their direct effects on the composition of carotid artery atherosclerotic plaques are unknown. To investigate the association of antithrombotic treatment with carotid artery plaque composition, with a specific focus on an intraplaque haemorrhage (IPH).

Methods and results

From the population-based Rotterdam Study, 1740 participants with carotid atherosclerosis on ultrasound (mean age 72.9 years, 46.0 women) underwent magnetic resonance imaging of the carotid arteries to assess plaque composition. Information on the use of oral anticoagulants [vitamin K antagonists (VKA)] and antiplatelet agents (salicylates), including duration of use and dosage, was obtained from pharmacy records for all participants. We used logistic regression models to assess the association between the use of anticoagulants and antiplatelet agents, and the different plaque components adjusting for confounders. Current and past use of VKA [adjusted odds ratio (OR): 1.88, 95% confidence interval (CI): 0.74-4.75 and OR 1.89, 95% CI: 0.91-3.93] and antiplatelet agents (OR: 1.22, 95% CI: 0.91-1.62), and (OR: 1.23, 95% CI: 0.86-1.75) showed positive trend with a higher presence of IPH. Also, a longer duration of use was associated with a higher frequency of IPH (OR: 3.15, 95% CI: 1.23-8.05) for the use of VKA, and longer duration of the use for antiplatelet agents showed a positive trend (OR: 1.21, 95% CI: 0.88-1.67). We also found that higher levels of international normalized ratio above 2.97 for VKA (OR: 1.48, 95% CI: 1.03-2.15) and higher daily defined dosage than 1.0 for antiplatelet agents (OR: 1.50, 95% CI: 1.21-1.87) were related to a higher frequency of IPH. We found no association with lipid core or calcification.

Conclusions

The use of antithrombotic treatment relates to a higher frequency of IPH in carotid atherosclerotic plaques.

MicroRNA-23a-5p promotes atherosclerotic plaque progression and vulnerability by repressing ATP-binding cassette transporter A1/G1 in macrophages

Disruption of carotid vulnerable atherosclerotic plaque is responsible for acute ischemic stroke (AIS) and the early detection and intervention approach are greatly limited. Undertaking a microarray of microRNAs (miRNAs) in the plasma of AIS patients with carotid vulnerable plaques, miR-23a-5p was markedly elevated and was positively correlated with the plaque progression and vulnerability. Correspondingly, we found that miR-23a-5p expression was significantly increased in both plasma and macrophages from atherosclerosis mice. Bioinformatics analysis and in vitro knockdown experiments identified that ATP-binding cassette transporter A1/G1 as a novel target of miR-23a-5p. Luciferase reporter assays showed that miR-23a-5p repressed the 3' untranslated regions (UTR) activity of ABCA1/G1. Moreover, functional analyses demonstrated that transfection of miR-23a-5p inhibitor enhanced cholesterol efflux and decreased foam cell formation through upregulating ABCA1/G1 expression levels. Furthermore, long term in vivo systemically delivered miR-23a-5p antagomir significantly increased ABCA1/G1 expression in the aorta of ApoE^-/- mice. Importantly, the miR-23a-5p antagomir therapy significantly reduced atherosclerosis progression and promoted plaque stability. Our observations indicate that miR-23a-5p promotes macrophage-derived foam cell formation and might be a key regulator contributing to atherosclerotic plaque progression and vulnerability.

Impact of Prolonged Inflation Times During Plain Balloon Angioplasty on Angiographic Dissection in Femoropopliteal Lesions

Purpose: To investigate if balloon angioplasty with a prolonged inflation time (>3 minutes) can prevent postdilation dissection in femoropopliteal lesions. Methods: A retrospective single-center analysis examined 294 consecutive patients (mean age 74.1±8.7 years; 215 men) with de novo femoropopliteal lesions treated with balloon angioplasty between 2013 and 2018. The patients were classified into 2 groups to compare angiographic dissection patterns: 175 patients treated with balloon angioplasty for 3 minutes (3-minute group) and 119 treated for >3 minutes (>3-minute group). Results: Mean balloon inflation time was 7.8±2.7 minutes in the >3-minute group. Severe dissections (type C or higher) were observed less frequently after balloon dilation in the >3-minute group (22.7% vs 50.9%, p<0.001); therefore, significantly more patients in the >3-minute group had successful endovascular treatment after initial balloon angioplasty (57.1% vs 38.3%, p=0.001). Additional balloon dilation was attempted more frequently in the 3-minute group (30.9% vs 14.3%, p=0.001); as a result, there were more patients in whom additional balloon dilation repaired severe dissection that occurred after the initial dilation (25.1% vs 10.9%, p=0.001). Multivariate analysis revealed that chronic total occlusion (p<0.001) and longer lesion (p<0.001) were independent predictors of severe dissection, and prolonged dilation time was independently related to preventing severe dissection (p<0.001). Among 171 patients undergoing successful balloon angioplasty without stent implantation, the Kaplan-Meier estimates of primary patency within 1 year did not differ significantly according to inflation time. Conclusion: Balloon dilation with prolonged inflation time (>3 minutes) may be effective as an initial strategy to prevent severe dissection in femoropopliteal lesions compared to inflation for 3 minutes.

Appropriateness of oral anticoagulant therapy prescription and its associated factors in hospitalized older people with atrial fibrillation

AIMS

Although oral anticoagulants (OACs) are effective in preventing stroke in older people with atrial fibrillation (AF), they are often underused in this particularly high-risk population. The aim of the present study was to assess the appropriateness of OAC prescription and its associated factors in hospitalized patients aged 65 years or older.

METHODS

Data were obtained from the retrospective phase of Simulation-based Technologies to Improve the Appropriate Use of Oral Anticoagulants in Hospitalized Elderly Patients With Atrial Fibrillation (SIM-AF) study, held in 32 Italian internal medicine and geriatric wards. The appropriateness of OAC prescription was assessed, grouping patients in those who were and were not prescribed OACs at hospital discharge. Multivariable logistic regression was used to establish factors independently associated with the appropriateness of OAC prescription.

RESULTS

A total of 328 patients were included in the retrospective phase of the study. Of these, almost 44% (N = 143) were inappropriately prescribed OACs, being mainly underprescribed or prescribed an inappropriate antithrombotic drug (N = 88). Among the patients prescribed OACs (N = 221), errors in the prescribed doses were the most frequent cause of inappropriate use (N = 55). Factors associated with a higher degree of patient frailty were inversely associated with the appropriateness of OAC prescription.

CONCLUSIONS

In hospitalized older patients with AF, there is still a high prevalence of inappropriate OAC prescribing. Characteristics usually related to frailty are associated with the inappropriate prescribing. These findings point to the need for targeted interventions designed for internists and geriatricians, aimed at improving the appropriate prescribing of OACs in this complex and high-risk population.

Use of the cardiovascular polypill 40mg in secondary cardiovascular prevention

Controlling cardiovascular risk factors (CV) is essential for patients with cardiovascular disease. The CV polypill contains aspirin 100mg, atorvastatin 20mg or 40mg, and ramipril 2.5mg, 5mg or 10mg in a fixed combination pill. The objective was to review the evidence on the secondary prevention of cardiovascular disease, to establish the eventual patient profiles suitables to consider the use of CV polypill with atorvastatin 40mg in secondary CV prevention (P40PS), and to define the priority situations most adequate for the use of P40PS. A bibliographic review was carried out, which was complemented with the clinical opinion of 19 specialists. During hospitalization and discharge, P40PS is an option for patients admitted because of an atherothrombotic event, peripheral arterial disease, or other causes, and with the indication of the monocomponents. Its priority use is proposed in: prior intolerance to the highest dose of atorvastatin (80mg), age>75 years, low weight, stage 3 of chronic renal failure, hypothyroidism, drug interactions and Asian origin. Outside the hospital setting, the P40PS is a therapeutic alternative in patients with a need for secondary CV prevention and with indication to receive the monocomponents. The priority situations to receive the P40PS are: to be taking the three components separately, to require polypharmacy, lack of adherence or understanding of the treatment, and lack of control of CV risk factors. This work is the first with proposals for the use of P40PS and can facilitate the treatment of patients with cardiovascular disease in secondary prevention.

Dilating Vascular Diseases: Pathophysiology and Clinical Aspects

Atherosclerotic disease of the vessels is a significant problem affecting mortality and morbidity all over the world. However, dilatation of the vessels either in the arterial system or in the venous territory is another vessel disease. Varicocele, pelvic, and peripheral varicose veins and hemorrhoids are aneurysms of the venous vascular regions and have been defined as dilating venous disease, recently. Coronary artery ectasia, intracranial aneurysm, and abdominal aortic aneurysm are examples of arterial dilating vascular diseases. Mostly, they have been defined as variants of atherosclerosis. Although there are some similarities in terms of pathogenesis, they are distinct from atherosclerotic disease of the vessels. In addition, pathophysiological and histological similarities and clinical coexistence of these diseases have been demonstrated both in the arterial and in the venous system. This situation underlies the thought that dilatation of the vessels in any vascular territory should be considered as a systemic vessel wall disease rather than being a local disease of any vessel. These patients should be evaluated for other dilating vascular diseases in a systematic manner.

Cardiovascular risk factors in adults with congenital heart defects - Recognised but not treated? An analysis of the German National Register for Congenital Heart Defects

BACKGROUND

As adult congenital heart disease (ACHD) patients are aging, a high prevalence of cardiovascular risk factors is encountered similar to the general population. Currently, data regarding the primary and secondary prevention of acquired cardiovascular disease in ACHD is lacking.

METHODS

The German National Register of Congenital Heart Defects was systematically screened for ACHD patients with established cardiovascular risk factors or documented acquired cardiovascular conditions. Data were analyzed with regard to the according medical treatment.

RESULTS

Overall, 539 patients were included (mean age 38.4 ± 17.7 years, 49.2% female). Diabetes was present in 57 pts. (10.6%), arterial hypertension in 113 pts. (21.0%), hyperlipidaemia in 81 pts. (15.0%) and obesity in 271 pts. (50.2%). 31 pts. (5.8%) were smokers. Coronary artery disease was established in 16 pts. (3.0%), peripheral vascular disease in 9 pts. (1.7%), and cerebrovascular accidents in 141 pts. (26.2%). Out of the patients with coronary artery disease only 81.3% received antithrombotic treatment. Only 18.8% were prescribed a statin. Of the pts. with peripheral arterial disease, 44.4% received an antiplatelet drug, and only 22.2% were on a statin. Patients with arterial hypertension received antihypertensive drugs in 66.4%.

CONCLUSIONS

Primary and secondary prevention of acquired cardiovascular disease in ACHD is underutilized. This highlights the importance of educating primary physicians as well as ACHD physicians about the need of primary and secondary prevention for acquired cardiovascular disease.

Screening for Peripheral Artery Disease Using the Ankle-Brachial Index: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Peripheral artery disease (PAD) is associated with a high risk for cardiovascular events and poor ambulatory function, even in the absence of symptoms. Screening for PAD with the ankle-brachial index (ABI) may identify patients in need of treatment to improve health outcomes.

OBJECTIVE

To systematically review evidence for the US Preventive Services Task Force on PAD screening with the ABI, the diagnostic accuracy of the test, and the benefits and harms of treatment of screen-detected PAD.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant English-language studies published between January 2012 and May 2, 2017. Surveillance continued through February 7, 2018.

STUDY SELECTION

Studies of unselected or generally asymptomatic adults with no known cardiovascular disease.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction by 2 reviewers.

MAIN OUTCOMES AND MEASURES

Cardiovascular morbidity; PAD morbidity; mortality; health-related quality of life; diagnostic accuracy; and serious adverse events.

RESULTS

Five studies (N = 5864 participants) were included that examined the indirect evidence for the benefits and harms of screening and treatment of screen-detected PAD. No population-based screening trials evaluated the direct benefits or harms of PAD screening with the ABI alone. A single diagnostic accuracy study of the ABI compared with magnetic resonance angiography gold-standard imaging (n = 306) found low sensitivity (7%-34%) and high specificity (96%-100%) in a screening population. Two adequately powered trials (n = 4626) in asymptomatic populations with and without diabetes with a variably defined low ABI (≤0.95 or ≤0.99) showed no statistically significant effect of aspirin (100 mg daily) for composite CVD outcomes (adjusted hazard ratio [HR], 1.00 [95% CI, 0.81-1.23] and HR, 0.98 [95% CI, 0.76-1.26]). One trial (n = 3350) demonstrated no statistically significant increase in major bleeding events with the use of aspirin (adjusted HR, 1.71 [95% CI, 0.99- 2.97]) and no statistically significant increase in major gastrointestinal bleeding (relative risk, 1.13 [95% CI, 0.44-2.91]). Two exercise trials (n = 932) in screen-relevant populations reported no differences in quality of life, Walking Impairment Questionnaire walking distance, or symptoms at 12 and 52 weeks; no harms were reported.

CONCLUSIONS AND RELEVANCE

There was no direct evidence and limited indirect evidence on the benefits of PAD screening with the ABI in unselected or asymptomatic populations. Available studies suggest low sensitivity and lack of beneficial effect on health outcomes, but these studies have important limitations.

THE POSSIBILITIES OF USING A NEW FIXED-DOSE COMBINATION OF ROSUVASTATIN AND ACETYLSALICYLIC ACID: FOCUS GROUPS OF PATIENTS

The review focuses on the impairment of the carotid, coronary arteries and lower-extremity arterial disease. Systemic involvement of various vascular beds in atherogenesis is emphasized. Epidemiological characteristics of morbidity and mortality from the main clinical manifestations of atherosclerosis - ischemic stroke, ischemic heart disease and lower-extremity arterial disease are given. The current principles of drug therapy are considered from the point of view of improving the prognosis and eliminating ischemia. The basic positions of International and Russian clinical recommendations on the management of patients with the presence of certain clinical manifestations of atherosclerosis are discussed. Detailed administration schemes and the preferred doses of statins and antiplatelet agents depending on the localization of atherosclerotic lesion and the severity of stenosis are described. The target blood lipids levels in the treatment with statins are given. The advantages of statins as drugs that reduce the risk of cardiovascular complications are presented. Current data on the pattern of antiplatelet use, including acetylsalicylic acid, in individuals with clinical manifestations of atherosclerosis are given. The principal tactic of dual antiplatelet therapy and schemes of its use in patients undergoing percutaneous coronary intervention, coronary artery bypass surgery and in individuals with a history of acute coronary disorders are considered.