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Preamble
It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices and procedures for the detection, management or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative benefits and risks of these therapies and procedures can improve the effectiveness of care, optimize patient outcomes and favorably affect the cost of care by focusing resources on the most effective strategies. One important use of such data is the production of clinical practice guidelines that, in turn, can provide a foundation for a variety of other applications, such as performance measures, appropriate use criteria, clinical decision support tools and quality improvement tools.
The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force) is charged with developing, updating and revising practice guidelines for cardiovascular diseases and procedures, and the Task Force directs and oversees this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update or revise recommendations for clinical practice.
Experts in the subject under consideration have been selected from both organizations to examine subject specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected health outcomes where data exist. Patient specific modifiers, comorbidities and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered but data on efficacy and clinical …
Footnotes
This article is a reprint of the paper that first appeared in the Journal of the American College of Cariology 2011;57:1002–44, doi:10.1016/j.jacc.2010.11.005. Copyright by and reprinted with permission from the American College of Cardiology Foundation and the American Heart Association Inc.
↵* Authors with no number by their name were included to provide additional content expertise apart from organizational representation.
Additional informations about the article are listed in the appendix.
Thomas G Brott and Jonathan L Halperin are Co-Chairs.
Provenance and peer review Not commissioned; not externally peer reviewed.
↵i Recommendations for revascularization in this section assume that operators are experienced, having successfully performed the procedures in >20 cases with proper technique and a low complication rate based on independent neurological evaluation before and after each procedure.
↵ii Non-disabling stroke is defined by a residual deficit associated with a score ≤2 according to the modified Rankin Scale.
↵iii The degree of stenosis is based on catheter based or non-invasive vascular imaging compared with the distal arterial lumen or velocity measurements by duplex ultrasonography. (See section 7 text in the full text version of the guideline for details.)
↵iv Conditions that produce unfavorable neck anatomy include, but are not limited to, arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis, previous ipsilateral CEA, contralateral vocal cord paralysis, open tracheostomy, radical surgery and irradiation.
↵v Comorbidities that increase the risk of revascularization include, but are not limited to, age >80 years, New York Heart Association class III or IV heart failure, left ventricular ejection fraction <30%, class III or IV angina pectoris, left main or multivessel coronary artery disease, need for cardiac surgery within 30 days, MI within 4 weeks and severe chronic lung disease.
↵vi In this context, severe disability refers generally to a modified Rankin Scale of ≥3, but individual assessment is required, and intervention may be appropriate in selected patients with considerable disability when a worse outcome is projected with continued medical therapy alone.