Massimo Fioranelli
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Linee Guida

L'enorme aumento della quantità e della complessità dell’informazione scientifica negli ultimi decenni è tale da rendere impossibile al medico prendere decisioni cliniche basate sui dati più aggiornati e completi, a meno che operi in ambiti di patologia molto limitati. Per ovviare a queste difficoltà sono stati sviluppati nuovi strumenti di informazione e di aiuto alla pratica medica: tra questi le rassegne (overviews) di letteratura, le analisi formali delle decisioni cliniche, le analisi economiche. Comune a questi strumenti è il fatto che essi raccolgono e sintetizzano l’informazione in modo da facilitare la decisione medica. Accanto a questi, sono state sviluppate le linee guida di pratica clinica (Clinical Practice Guidelines) come uno strumento che ha un obiettivo più ambizioso: quello di fornire al clinico non solo informazioni, ma anche raccomandazioni sul modo più corretto di trattare i propri malati in particolari situazioni patologiche. Si tratta perciò di uno strumento non meramente informativo, ma in certo modo di uno strumento normativo, anche se - naturalmente - non vincolante per il clinico.

AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes (2014)

The recommendations listed in this CPG are, whenever possible, evidence based. An extensive evidence review was conducted through October 2012, and others elected references published through April 2014 were reviewed by the GWC. Literature included was derived from research involving humans ubjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality Reports, and others elected databases relevant to this CPG. The relevant data are included in evidence tables in the On line Data Supplement.


Third universal definition of myocardial infarction (2012)

Myocardial infarction (MI) can be recognised by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology. It is a major cause of death and disability worldwide. MI may be the first manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients with established disease. Information on MI rates can provide useful information regarding the burden of CAD within and across populations, especially if standardized data are collected in a manner that distinguishes between incident and recurrent events. From the epidemiological point of view, the incidence of MI in a population can be used as a proxy for the prevalence of CAD in that population. The term 'myocardial infarction' may have major psychological and legal implications for the individual and society. It is an indicator of one of the leading health problems in the world and it is an outcome measure in clinical trials, observational studies and quality assurance programmes. These studies and programmes require a precise and consistent definition of MI..


Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines,and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European Cohort (2014)

Prevention of cardiovascular disease (CVD), the leading cause of death worldwide, remains feasible yet sub-optimal. The common approach in CVD primary prevention is to identify individuals at high enough risk for cardiovascular events to justify targeting them for more intensive lifestyle interventions, pharmacological interventions,or both.


Guidelines on cardiac pacing and cardiac resynchronization therapy: Addenda (version 2013)

The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA).


Ictus cerebrale: linee guida italiane di prevenzione e trattamento

Il gruppo di lavoro che ha sviluppato queste linee guida – la SPREAD Collaboration – rappresenta il modo concreto per ottenere il requisito di multidisciplinarietà. La multidisciplinarietà è stata ricercata coinvolgendo rappresentanti di tutte quelle professionalità e funzioni che, in diversi momenti, possono essere coinvolte nell’applicazione – come soggetto attivo o passivo – delle linee guida. Nella stesura di queste linee guida sono stati coinvolti alcuni referenti dell’utenza (associazioni di pazienti e familiari) e, al fine di considerare gli aspetti multiprofessionali relativi al personale sanitario non medico, sono stati coinvolti nel processo di revisione gruppi di infermieri, logopedisti e terapisti della riabilitazione.

Linee guida 2007 per il trattamento dell’ipertensione arteriosa

A cura del Comitato per la stesura delle Linee Guida della Società Europea di Ipertensione Arteriosa (ESH) e della Società Europea di Cardiologia (ESC)
Tradotto da 2007 Guidelines for the management of arterial hypertension. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2007; 28: 1462-536.

Linee guida per la diagnosi e il trattamento delle sindromi coronariche acute senza sopraslivellamento del tratto ST

Task Force per la Diagnosi e il Trattamento delle Sindromi Coronariche Acute Senza Sopraslivellamento del Tratto ST della Società Europea di Cardiologia
Tradotto da Guidelines for the diagnosis and treatment of non-STsegment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 2007; 28: 1598-660.

Guidelines for the diagnosis and management of syncope (version 2009)

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk/ benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been previously discussed.
The first ESC Guidelines for the management of syncope, were published in 2001, and reviewed in 2004.1 In March 2008, the CPG considered that there were enough new data to justify production of new guidelines.


Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery

The present guidelines focus on the cardiological management of patients undergoing non-cardiac surgery, i.e. patients where heart disease is a potential source of complications during surgery. The risk of perioperative complications depends on the condition of the patient prior to surgery, the prevalence of co-morbidities, and the magnitude and duration of the surgical procedure.3 More specifically, cardiac complications can arise in patients with documented or asymptomatic ischaemic heart disease (IHD), left ventricular (LV) dysfunction, and valvular heart disease (VHD) who undergo procedures that are associated with prolonged haemodynamic and cardiac stress. In the case of perioperative myocardial ischaemia, two mechanisms are important: (i) chronic mismatch in the supply-to-demand ratio of blood flow response to metabolic demand, which clinically resembles stable IHD due to a flow limiting stenosis in coronary conduit arteries; and (ii) coronary plaque rupture due to vascular inflammatory processes presenting as acute coronary syndromes (ACSs). Hence, although LV dysfunction may occur for various reasons in younger age groups, perioperative cardiac mortality and morbidity are predominantly an issue in the adult population undergoing major non-cardiac surgery.


ACC/AHA/NASPE Guideline for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices (version 2002)

ACC/AHA/NASPE 2002 Guideline Revision: Guiding Principles
  • Changes reflect new clinical evidence, results from randomized clinical trials and clinical consensus.
  • Healthcare, logistic, and financial implications of new evidence were considered in classifying indications.
  • Made prior wording more precise when needed.
  • Recommendations apply to ?most? patients, but the treating physician may modify based on an individual patient?s situation.
  • Recommendations presume absence of inciting causes that may be eliminated without detriment to the patient.
  • Efforts were made to maintain consistency with other related guidelines.


ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)
The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. This effort is directed by the ACC/AHA Task Force on Practice Guidelines, whose charge is to develop and revise practice guidelines for important cardiovascular diseases and procedures. The Task Force is pleased to have this guideline cosponsored by the Society for Cardiovascular Angiography and Interventions (SCAI). Experts in the subject under consideration have been selected from all three organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups where appropriate. Writing groups are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered, as well as frequency of follow-up and cost-effectiveness. When available, information from studies on cost will be considered; however, review of data on efficacy and clinical outcomes will be the primary basis for preparing recommendations in these guidelines.


Guidelines on the management of stable angina pectoris

The Task Force on the Managemt of Stable Angina Pectoris of the European Society of Cardiology
Stable angina pectoris is a common and disabling disorder. However, the managemt of stable angina has not been subjected to the same scritiny by large randomized trials as has, for example, that of acute corinary symdromes (ACS) including unstable angina and Myocardial infarction (MI). The optimal strategy of investigation and treatment is difficult to define, and the developement of new tools for the diagnostic and prognostic assessment of patients, along with the continually evolving evidence base for various treatment strategies, mandates that the existing guidelines be revised and updated.


Guidelines on Heart rate variability (HRV)

Standards of measurement, physiological interpretation, and clinical use.

Task Force of The European Society of Cardiology and The North American Society of Pacing and Electrophysiology (Membership of the Task Force listed in the Appendix)
The last two decades have witnessed the recognition of a significant relationship between the autonomic nervous system and cardiovascular mortality, including sudden cardiac death. Experimental evidence for an association between a propensity for lethal arrhythmias and signs of either increased sympathetic or reduced vagal activity has encouraged the development of quantitative markers of autonomic activity.
Heart rate variability (HRV) represents one of the most promising such markers. The apparently easy derivation of this measure has popularized its use. As many commercial devices now provide automated measurement of HRV, the cardiologist has been provided with a seemingly simple tool for both research and clinical studies[5]. However, the significance and meaning of the many different measures of HRV are more complex than generally appreciated and there is a potential for incorrect conclusions and for excessive or unfounded extrapolations.


Based on the ACC/AHA guidelines for the Management of Patientes with ST-Elevation Myocardial Infarction (STEMI) (April 2005)

What’s new in the Device-Based Therapy Guidelines?

Based on the ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities.


Guidelines For Device Based Therapy Indications in Adults (2008 Summary)

This slide set was adapted from the ACC/AHA Guidelines for Management of Patients With ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology 2004;44:671-719, e1-e211 and Circulation 2004;44:671-619, e82-e292).
The full-text guidelines and executive summary are also available on the Web sites: ACC ( ) and, AHA (


ACC/AHA 2007 STEMI Guidelines

Based on the 2007 Focused Update of the ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (STEMI): A Report of the ACC/AHA Task Force on Practice Guidelines
The full-text guidelines and executive summary are also available on the Web sites: ACC ( ) and, AHA (


Transcatheter valve implantation for patients with aortic stenosis

Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery(EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions(EAPCI).


Consensus Document on Cardiovascular Magnetic Resonance 2010

This document was developed by the American College of Cardiology Foundation (ACCF) Task Force on Clinical Expert Consensus Documents (ECDs) and cosponsored by the American Collegeof Radiology (ACR), American Heart Association (AHA), North American Society for Cardiovascular Imaging (NASCI), and the Society for Cardiovascular Magnetic Resonance (SCMR), to provide a perspective on the current state of cardiovascular magnetic resonance (CMR). ECDs are intended to inform practitioners and other interested parties of the opinion of the ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics are chosen for coverage be cause the evidence base, the experience with technology, and/or theclinical practice are not considered suf?ciently well developed to be evaluated by the formal ACCF/AHA practice guidelines process. Often the topicis the subject of ongoing investigation.


Consensus Document on Coronary Computed Tomographic Angiography 2010

This document was reviewed by 15 official representatives from the ACCF (2 representatives ), ACR (2 representatives), AHA (2 representatives ), ASNC (1 representative ) NASCI (2 representatives ), SAIP ( 2 representatives ), SCAI (2 representatives ), and SCCT (2 representatives), as well as 10 content reviewers, resulting in 518 peer review comments. Peer review comments were entered into a table and reviewed in detail by the writing committee chair. The chair engaged writing committee members to respond to the comments, and the document was revised to incorporate reviewer comments where deemed appropriate by the writing committee. In addition, a member of the ACCF Task Force on Clinical ECDs served as lead reviewer for this document. This person conducted an independent review of the document at the time of peer review. Once the writing committee document edits response to reviewer comments and updated the manuscript, the lead reviewer assessed whether all peer review issues were handled adequately or whether there were gaps that required additional review The lead reviewer reported to the task force chair that all comments were handled appropriately and recommended that the document go forward to the task force for ?nal review and sign-off.


ACC/AHA/SCAI guideline summary: Intravascular ultrasound (IVUS) at the time of percutaneous coronary intervention (PCI)

Data from Smith, SC Jr, Feldman, TE, Hirshfeld, JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1.


Guidelines for Mitral-Valve Operation; American College of Cardiology–American Heart Association 2006

ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114(5):e84-e231. [Erratum, Circulation 2007;115(5):e409.]


Guidelines on Myocardial Revascularization

Myocardial revascularization has been an established mainstay in the treatment of CAD for almost half a century. Coronary artery bypass grafting (CABG), used in clinical practice since the 1960s, is arguably the most intensively studied surgical procedure ever undertaken, while percutaneous coronary intervention (PCI), used for over three decades, has been subjected to more randomized clinical trials (RCTs) than any other interventional procedure. PCI was ?rst introduced in 1977 by Andreas Gruentzig and by the mid-1980s was promoted as an alternative to CABG.


Linee guida ERC (European Resusciattion Council) sulla Rianimazione Cardiopolmonare (RCP)

Le linee guida ERC (European Resuscitation Council) 2010 sulla rianimazione cardiopolmonare (RCP) aggiornano quelle pubblicate nel 2005 e rispettano il ciclo quinquennale di revisioni previste per le modifiche alle linee guida. Come le precedenti, le nuove linee guida del 2010 sono basate sul più recente Consenso Scientifico Internazionale sulla Rianimazione Cardiopolmonare con Raccomandazioni sul Trattamento (CoSTR) che ha riunito i risultati di revisioni sistematiche nell’ambito di un’ampia serie di argomenti relativi alla RCP.
La scienza della rianimazione è in continua evoluzione e le linee guida cliniche devono essere regolarmente aggiornate per seguire il progresso scientifico ed indirizzare il personale sanitario sul miglior approccio da seguire nella pratica clinica. Nei cinque anni che intercorrono tra gli aggiornamenti delle linee guida, comunicazioni scientifiche provvisorie possono informare il personale sanitario sulle nuove terapie che potrebbero influenzare significativamente la prognosi.


2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA
2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non cardiac Surgery

Patient adherence to prescribed and agreed upon medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles.
If these guidelines are used as the basis for regulatory or payer decisions, the goal should be quality of care and the patient’s best interest. The ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all of the circumstances presented by that patient. Consequently, there are circumstances in which deviations from these guidelines are appropriate. The guidelines will be reviewed annually by the ACCF/AHA Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution.


ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly

A report developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologist, and European Society of Hypertension.
This document was written with the intent to be a complete reference at the time of publication on the topic of managing hypertension in the elderly.


2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease

The ACCF/AHA writing committee to create the 2011 Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (ECVD) conducted a comprehensive review of the literature relevant to carotid and vertebral artery interventions through May 2010.
The recommendations listed in this document are, whenever possible, evidence-based. Searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English.
Key search words included but were not limited to angioplasty, atherosclerosis, carotid artery disease, carotid endarterectomy(CEA), carotid revascularization, carotid stenosis, carotid stenting, carotid arterystenting(CAS), extracranial carotid artery stenosis, stroke, transient ischemic attack(TIA), and vertebral artery disease.


2013 ACCF/AHA Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Acute Coronary Syndromes and Coronary Artery Disease

In the field of cardiology, large-scale clinical trials and registries have provided a wealth of data on the treatment and outcomes for hundreds of thousands of patients. Many of these efforts have focused on patients with acute coronary syndromes (ACS), which range from ST-segment elevation myocardial infarction (STEMI) to non–ST-segment elevation myocardial infarction (NSTEMI) to unstable angina (UA). These data have been used to evaluate the effectiveness of the pharmacological and interventional management of these patients, de?ne new therapies, and guide clinical care through evaluation of both the process and the quality of care and outcomes for patients with ACS.


2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specifc interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.





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