IntroductionPeripheral arterial disease (PAD) is the third leading atherosclerotic arterial disease. There is evidence that there is a high variation in the quality and recommendations of clinical practice guidelines for PAD, leading to the possibility of confusion among clinicians and patients. This study aims to conduct a quality assessment and comparative analysis of the clinical practice guidelines on PAD written between 2010 and 2020.Method and analysisWe aim to perform a systematic review of clinical practice guidelines written between 2010 and 2020. A search for guidelines will be conducted through medical databases Scope, Pubmed, TRIP, Guideline Clearinghouses and specialist international organisations’ specific websites. Guidelines that meet the inclusion criteria will be extracted from the search result. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II instrument) will assess the quality of the selected guidelines. The recommendations, level of evidence and other relevant information will be extracted in a datasheet for qualitative analysis. The score for each guideline’s quality will be represented using charts and central tendency measures for comparison. The summary of recommendations will also be represented in tables for easy comparison for similarities and variations across sections. Finally, the level of evidence on which the recommendations are based will also be noted along with other significant characteristics such as the authors’ financial relationship to the biomedical community. We aim to point out deficiencies present in current guidelines and elucidate areas where recommendations are made with low-level evidence. The results will enable the scientific community to design future research to fill in PAD management knowledge gaps.Ethics and disseminationNo ethical approval was sought. Dissemination will be via journal articles and conference presentations.PROSPERO registration numberCRD42020219176.

We would like to alert readers to factual errors and omissions in a review recently published in Angiology by Paraskevas et al that may encourage continued overuse of invasive carotid artery procedures. 1 Further, most of these exist in other reviews as specifically indicated below. 2,3 1. A flawed interpretation is that some recent guidelines are suitably more restrictive in endorsing 'revascularisation' procedures for asymptomatic carotid stenosis (ACS) patients by specifying, 4,5 or at least considering, 6 so-called 'high stroke risk' features. [1][2][3] Superficially, this may seem reasonable. However, those so-called high stroke risk features have not been proven in the context of current, optimal, medical intervention (lifestyle coaching and medication) and not all have been identified as high stroke risk markers. 7,8 As a group they cover just about all ACS patients, and often individual markers alone are far too common to identify those likely to benefit from a carotid procedure. 7,8 In effect, recent guidelines 4-6,9 can be used to justify a carotid procedure on just about anyone with advanced ACS. 7,8,10 Further, the authors did not mention the highest absolute annual ipsilateral stroke rate (∼3%) in the meta-analysis by Howard et al, which examined stroke rate according to ACS degree. 1,11 Absolute annual event rates are much more informative than odds or hazards ratios. Stroke rates in the metaanalysis by Howard et al are not reflective of current best (or 'intensive') medical intervention. 1,3,11 We can expect to significantly lower this ipsilateral stroke rate, to 1.5% or less. 12 2. The authors did not acknowledge that the only ACS patients ever to significantly benefit in randomised trials from carotid endarterectomy (CEA) compared to medical intervention alone were highly selected men aged <75-80 years and that the stroke risk reduction benefit for them was small (1%/year). 1-3 Moreover, it was not acknowledged that evidence for this CEA benefit no longer exists due to marked

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ObjectivesThere are several clinical practice guidelines available for peripheral artery disease (PAD). The paucity of strong evidence is known to give room for variations in recommendations across guidelines, with attendant confusion among clinicians in clinical practice. This study aims to conduct a quality assessment and comparative analysis on PAD screening and diagnostic recommendations in PAD management.SelectionClinical practice guidelines written after 2010 and on or before 2020 were targeted. An exhaustive search was conducted through the major medical databases and websites of specialist international organisations of interest, and selection was made using our inclusion/exclusion criteria.SettingGlobal. All guidelines written in English were included in this study.Selected guidelinesNine guidelines were selected.OutcomesThe primary outcomes were the guidelines’ quality and variations in screening and diagnostic recommendations in the selected guidelines.ResultsRegarding quality, the guidelines had the lowest scores across the applicability and stakeholder involvement domains with means (SD) of 62 (9.9) and 65.3 (13), respectively. The highest score was clarity of presentation, with a mean (SD) of 86.8 (5.1). Also, the trend showed guideline quality scores improved over time. The guidelines unanimously offered to screen ‘high-risk’ patients, although there were some discrepancies in the appropriate age range and unavailability of strong evidence backing this recommendation. The guidelines harmoniously adopted the Ankle-Brachial Index as the initial diagnostic investigation of choice. However, concerning further diagnostic investigations and imaging, we found several discrepancies among the recommendations in the absence of strong evidence.ConclusionThough the quality of the guidelines is shown to be improving over time, they perform poorly in stakeholder involvement and applicability domains, which could be influencing interest in research revolving around screening and diagnostic recommendations. Involving primary care providers and the public can be a possible solution.PROSPERO registration numberCRD42020219176.

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