January 16, 2019

Study Evaluates Strength of Evidence Underlying the AHA/ACC Guidelines on Treating Peripheral Vascular Disease

January 16, 2019—Findings from a study evaluating the evidence base supporting the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines on peripheral vascular interventions (PVIs) were published by Partha Sardar, MD, et al online in Circulation: Cardiovascular Interventions. The investigators concluded that there is significant variation in the level of evidence (LOE) supporting various PVIs in the current guidelines. They stated that, overall, the availability of high-quality evidence remains low and that the LOE appears insufficient to support many guideline recommendations for PVI.

These findings highlight the need for more objective and comparative evidence to support the use of endovascular and surgical therapies and, in some areas, for updated guidelines, advised the investigators.

As summarized in Circulation: Cardiovascular Interventions, AHA/ACC guideline documents available as of May 2018 were abstracted for both endovascular and surgical PVI. The number of recommendations, class of recommendations (I, II, and III), and the distribution of their respective LOEs (A, B, and C) were determined for each procedure. Guidelines were also evaluated for changes in recommendations over time.

Of the 134 recommendations reported in five current guidelines, the investigators found that only 13% were supported by LOE A and 39% were supported by LOE C. Overall, most recommendations were class II (54%), while 35% were class I.

Lower LOEs were observed for interventions for:

  • Pulmonary embolism/deep vein thrombosis (DVT) (A, 0%; B, 24%; C, 76%)
  • Inferior vena cava filter (A, 0%; B, 31%; C, 69%)
  • Renal artery stenosis (A, 0%; B, 67%; C, 33%)

A comparatively higher LOE A was observed for endovascular stroke therapy (24%).

Compared with previous versions, the total number of recommendations for lower extremity peripheral artery disease (PAD) in the current guideline decreased from 49 to 26, without an improvement in high-quality evidence, reported the investigators in Circulation: Cardiovascular Interventions.

In comments to Endovascular Today, study Co-Investigator Michael R. Jaff, DO, observed, “It is not surprising to me that the evidence base for clinical decision-making around PVI is lacking. Most of the trials for device approval in PAD, for example, at least in the United States, have been prospective, single-arm, multicenter registries. Things are even more problematic in the arena of acute venous thromboembolic diseases (ie, DVT and pulmonary embolism), where comparative trials are just starting to emerge. We felt it important to point this out and suggest that as clinicians, we have an obligation to our patients to raise the bar of comparative effectiveness by performing high levels of evidence for high-quality studies. There are signals that this is beginning to happen, and this holds great promise for our patients and for those of us practicing in the field.”


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