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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>National Clinical Guideline Centre (UK). Lower Limb Peripheral Arterial Disease: Diagnosis and Management [Internet]. London: Royal College of Physicians (UK); 2012 Aug. (NICE Clinical Guidelines, No. 147.)</p></div><div class="bk_msg_box bk_bttm_mrgn clearfix bk_noprnt"><div class="iconblock clearfix"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/nicecg147guid/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg147guid-lrg.png" alt="Cover" height="100px" width="80px" /></a><div class="icnblk_cntnt"><ul class="messages"><li class="info icon"><span class="icon"><a href="/books/n/nicecg147guid/">See 2020 Partial Update</a></span></li></ul></div></div></div><div class="messagearea bk_noprnt" style="margin-bottom:1.3846em "><ul class="messages"><li class="warn icon"><span class="icon">Update information: This guideline was updated by a NICE standing committee in February 2018 and 2 new recommendations were added on diagnosing peripheral arterial disease in people with diabetes. The recommendations are in section 1.3 of the guidance. The evidence for these recommendations is in evidence reviews A: determining the diagnosis and severity of peripheral arterial disease in people with diabetes. December 2020: NICE added links in the recommendation on pain relief to other NICE guidelines and resources that support discussion with patients about opioid prescribing and safe withdrawal management. For the current recommendations, see www.nice.org.uk/guidance/CG147/chapter/recommendations. October 2018: The antiplatelet therapy link in recommendation 1.2.1 was updated.</span></li></ul></div><div class="bk_prnt"><p style="color:red;"><strong>Update information: This guideline was updated by a NICE standing committee in February 2018 and 2 new recommendations were added on diagnosing peripheral arterial disease in people with diabetes. The recommendations are in section 1.3 of the guidance. The evidence for these recommendations is in evidence reviews A: determining the diagnosis and severity of peripheral arterial disease in people with diabetes. December 2020: NICE added links in the recommendation on pain relief to other NICE guidelines and resources that support discussion with patients about opioid prescribing and safe withdrawal management. For the current recommendations, see www.nice.org.uk/guidance/CG147/chapter/recommendations. October 2018: The antiplatelet therapy link in recommendation 1.2.1 was updated.</strong></p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/nicecg147/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg147-lrg.png" alt="Cover of Lower Limb Peripheral Arterial Disease" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>Lower Limb Peripheral Arterial Disease: Diagnosis and Management [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK327460_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK327460_dtls__"><div>NICE Clinical Guidelines, No. 147.</div><div>National Clinical Guideline Centre (UK).</div><div>London: <a href="http://www.rcplondon.ac.uk/Pages/index.aspx" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">Royal College of Physicians (UK)</a>; 2012 Aug.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/nicecg147/">Contents</a></li></ul></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/nicecg147/ch3/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/nicecg147/ch5/" title="Next page in this title">Next ></a></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK327460_"><span class="label"> 4</span><span class="title" itemprop="name">Guideline summary</span></h1></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="ch4.s1"><h2 id="_ch4_s1_">4.1. Key priorities for implementation</h2><p>From the full set of recommendations, the GDG selected 9 key priorities for implementation. They selected recommendations that would:</p><ul><li class="half_rhythm"><div>Have a high impact on outcomes that are important to patients</div></li><li class="half_rhythm"><div>Have a high impact on reducing variation in care and outcomes</div></li><li class="half_rhythm"><div>Lead to a more efficient use of NHS resources</div></li><li class="half_rhythm"><div>Promote patient choice</div></li><li class="half_rhythm"><div>Promote equality.</div></li></ul><p>In addition to this, the GDG also considered which recommendations were particularly likely to benefit from implementation support. They considered whether a recommendation:</p><ul><li class="half_rhythm"><div>Relates to an intervention that is not part of routine care</div></li><li class="half_rhythm"><div>Requires changes in service delivery</div></li><li class="half_rhythm"><div>Requires retraining of staff of the development of new skills and competencies</div></li><li class="half_rhythm"><div>Highlights the need for practice change</div></li><li class="half_rhythm"><div>Affects an needs to be implemented across a number of agencies or settings (complex interactions)</div></li><li class="half_rhythm"><div>May be viewed as potentially contentious, or difficult to implement for other reasons.</div></li></ul><p>The reasons that each of these recommendations was chosen are shown in the table linking the evidence to the recommendation in the relevant chapter.</p><div id="ch4.s2"><h3>4.1.1. The recommendations identified as priorities for implementation are</h3><div id="ch4.s3"><h4>Information requirement for people with peripheral arterial disease</h4><ul><li class="half_rhythm"><div>Offer all people with peripheral arterial disease oral and written information about their condition. Discuss it with them so they can share decision-making, and understand the course of the disease and what they can do to help prevent disease progression. Information should include:</div><ul class="circle"><li class="half_rhythm"><div>the causes of their symptoms and the severity of their disease</div></li><li class="half_rhythm"><div>the risks of limb loss and/or cardiovascular events associated with peripheral arterial disease</div></li><li class="half_rhythm"><div>the key modifiable risk factors, such as smoking, control of diabetes, hyperlipidaemia, diet, body weight and exercise (see also recommendation on secondary prevention of cardiovascular disease)</div></li><li class="half_rhythm"><div>how to manage pain</div></li><li class="half_rhythm"><div>all relevant treatment options, including the risks and benefits of each</div></li><li class="half_rhythm"><div>how they can access support for dealing with depression and anxiety.</div></li></ul></li></ul><p>Ensure that information, tailored to the individual needs of the person, is available at diagnosis and subsequently as required, to allow people to make decisions throughout the course of their treatment.</p></div><div id="ch4.s4"><h4>Secondary prevention of cardiovascular disease in people with peripheral arterial disease</h4><ul><li class="half_rhythm"><div>Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance (see <a href="/books/n/nicecg147/ch2/#ch2.s6">section 2.6</a>) on:</div><ul class="circle"><li class="half_rhythm"><div>smoking cessation</div></li><li class="half_rhythm"><div>diet, weight management and exercise</div></li><li class="half_rhythm"><div>lipid modification and statin therapy</div></li><li class="half_rhythm"><div>the prevention, diagnosis and management of diabetes</div></li><li class="half_rhythm"><div>the prevention, diagnosis and management of high blood pressure</div></li><li class="half_rhythm"><div>antiplatelet therapy.</div></li></ul></li></ul></div><div id="ch4.s5"><h4>Diagnosis</h4><ul><li class="half_rhythm"><div>Assess people for the presence of peripheral arterial disease if they:</div><ul class="circle"><li class="half_rhythm"><div>have symptoms suggestive of peripheral arterial disease or</div></li><li class="half_rhythm"><div>have diabetes, non-healing wounds on the legs or feet or unexplained leg pain or</div></li><li class="half_rhythm"><div>are being considered for interventions to the leg or foot or</div></li><li class="half_rhythm"><div>need to use compression hosiery.</div></li></ul></li><li class="half_rhythm"><div>Assess people with suspected peripheral arterial disease by:</div><ul class="circle"><li class="half_rhythm"><div>asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia</div></li><li class="half_rhythm"><div>examining the legs and feet for evidence of critical limb ischaemia, for example ulceration</div></li><li class="half_rhythm"><div>examining the femoral, popliteal and foot pulses</div></li><li class="half_rhythm"><div>measuring the ankle brachial pressure index (see recommendation below).</div></li></ul></li><li class="half_rhythm"><div>Measure the ankle brachial pressure index in the following way:</div><ul class="circle"><li class="half_rhythm"><div>The person should be resting and supine if possible.</div></li><li class="half_rhythm"><div>Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis and, where possible, peroneal arteries.</div></li><li class="half_rhythm"><div>Take measurements manually using a Doppler probe of suitable frequency in preference to an automated system.</div></li><li class="half_rhythm"><div>Document the nature of the Doppler ultrasound signals in the foot arteries.</div></li><li class="half_rhythm"><div>Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure.</div></li></ul></li></ul></div><div id="ch4.s6"><h4>Imaging for revascularisation</h4><ul><li class="half_rhythm"><div>Offer contrast-enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.</div></li></ul></div><div id="ch4.s7"><h4>Management of intermittent claudication</h4><ul><li class="half_rhythm"><div>Offer a supervised exercise programme to all people with intermittent claudication.</div></li></ul></div><div id="ch4.s8"><h4>Management of critical limb ischaemia</h4><ul><li class="half_rhythm"><div>Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.</div></li><li class="half_rhythm"><div>Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.</div></li></ul></div></div></div><div id="ch4.s9"><h2 id="_ch4_s9_">4.2. Full list of recommendations</h2><div id="ch4.s10"><h3>4.2.1. Information requirements</h3><ol><li class="half_rhythm"><div class="half_rhythm">Offer all people with peripheral arterial disease oral and written information about their condition. Discuss it with them so they can share decision-making, and understand the course of the disease and what they can do to help prevent disease progression. Information should include:</div><ul class="circle"><li class="half_rhythm"><div>the causes of their symptoms and the severity of their disease</div></li><li class="half_rhythm"><div>the risks of limb loss and/or cardiovascular events associated with peripheral arterial disease</div></li><li class="half_rhythm"><div>the key modifiable risk factors, such as smoking, control of diabetes, hyperlipidaemia, diet, body weight and exercise (see also recommendation 3)</div></li><li class="half_rhythm"><div>how to manage pain</div></li><li class="half_rhythm"><div>all relevant treatment options, including the risks and benefits of each</div></li><li class="half_rhythm"><div>how they can access support for dealing with depression and anxiety.</div></li></ul><div class="half_rhythm">Ensure that information, tailored to the individual needs of the person, is available at diagnosis and subsequently as required, to allow people to make decisions throughout the course of their treatment.</div></li><li class="half_rhythm"><div class="half_rhythm">NICE has produced guidance on the components of good patient experience in adult NHS services. Follow the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138).</div></li></ol></div><div id="ch4.s11"><h3>4.2.2. Secondary prevention of cardiovascular disease in people with peripheral arterial disease</h3><dl class="temp-labeled-list"><dt>3.</dt><dd><p class="no_top_margin">Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance (see ‘Related NICE guidance’; <a href="/books/n/nicecg147/ch2/#ch2.s6">section 2.6</a>) on:</p><ul class="circle"><li class="half_rhythm"><div>smoking cessation</div></li><li class="half_rhythm"><div>diet, weight management and exercise</div></li><li class="half_rhythm"><div>lipid modification and statin therapy</div></li><li class="half_rhythm"><div>the prevention, diagnosis and management of diabetes</div></li><li class="half_rhythm"><div>the prevention, diagnosis and management of high blood pressure</div></li><li class="half_rhythm"><div>antiplatelet therapy.</div></li></ul></dd></dl></div><div id="ch4.s12"><h3>4.2.3. Diagnosis</h3><dl class="temp-labeled-list"><dt>4.</dt><dd><p class="no_top_margin">Assess people for the presence of peripheral arterial disease if they:</p><ul class="circle"><li class="half_rhythm"><div>have symptoms suggestive of peripheral arterial disease or</div></li><li class="half_rhythm"><div>have diabetes, non-healing wounds on the legs or feet or unexplained leg pain or</div></li><li class="half_rhythm"><div>are being considered for interventions to the leg or foot or</div></li><li class="half_rhythm"><div>need to use compression hosiery.</div></li></ul></dd><dt>5.</dt><dd><p class="no_top_margin">Assess people with suspected peripheral arterial disease by:</p><ul class="circle"><li class="half_rhythm"><div>asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia</div></li><li class="half_rhythm"><div>examining the legs and feet for evidence of critical limb ischaemia, for example ulceration</div></li><li class="half_rhythm"><div>examining the femoral, popliteal and foot pulses</div></li><li class="half_rhythm"><div>measuring the ankle brachial pressure index (see recommendation 6).</div></li></ul></dd><dt>6.</dt><dd><p class="no_top_margin">Measure the ankle brachial pressure index in the following way:</p><ul class="circle"><li class="half_rhythm"><div>The person should be resting and supine if possible.</div></li><li class="half_rhythm"><div>Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis and, where possible, peroneal arteries.</div></li><li class="half_rhythm"><div>Take measurements manually using a Doppler probe of suitable frequency in preference to an automated system.</div></li><li class="half_rhythm"><div>Document the nature of the Doppler ultrasound signals in the foot arteries.</div></li><li class="half_rhythm"><div>Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure.</div></li></ul></dd></dl></div><div id="ch4.s13"><h3>4.2.4. Imaging for revascularisation</h3><dl class="temp-labeled-list"><dt>7.</dt><dd><p class="no_top_margin">Offer duplex ultrasound as first-line imaging to all people with peripheral arterial disease for whom revascularisation is being considered.</p></dd><dt>8.</dt><dd><p class="no_top_margin">Offer contrast-enhanced magnetic resonance angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) before considering revascularisation.</p></dd><dt>9.</dt><dd><p class="no_top_margin">Offer computed tomography angiography to people with peripheral arterial disease who need further imaging (after duplex ultrasound) if contrast-enhanced magnetic resonance angiography is contraindicated or not tolerated.</p></dd></dl></div><div id="ch4.s14"><h3>4.2.5. Management of intermittent claudication</h3><div id="ch4.s15"><h4>4.2.5.1. Supervised exercise programme</h4><dl class="temp-labeled-list"><dt>10.</dt><dd><p class="no_top_margin">Offer a supervised exercise programme to all people with intermittent claudication.</p></dd><dt>11.</dt><dd><p class="no_top_margin">Consider providing a supervised exercise programme for people with intermittent claudication which involves:</p><ul class="circle"><li class="half_rhythm"><div>2 hours of supervised exercise a week for a 3-month period</div></li><li class="half_rhythm"><div>encouraging people to exercise to the point of maximal pain.</div></li></ul></dd></dl></div><div id="ch4.s16"><h4>4.2.5.2. Angioplasty and stenting</h4><dl class="temp-labeled-list"><dt>12.</dt><dd><p class="no_top_margin">Offer angioplasty for treating people with intermittent claudication only when:</p><ul class="circle"><li class="half_rhythm"><div>advice on the benefits of modifying risk factors has been reinforced (see recommendation 3) and</div></li><li class="half_rhythm"><div>a supervised exercise programme has not led to a satisfactory improvement in symptoms and</div></li><li class="half_rhythm"><div>imaging has confirmed that angioplasty is suitable for the person.</div></li></ul></dd><dt>13.</dt><dd><p class="no_top_margin">Do not offer primary stent placement for treating people with intermittent claudication caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease.</p></dd><dt>14.</dt><dd><p class="no_top_margin">Consider primary stent placement for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis).</p></dd><dt>15.</dt><dd><p class="no_top_margin">Use bare metal stents when stenting is used for treating people with intermittent claudication.</p></dd></dl></div><div id="ch4.s17"><h4>4.2.5.3. Bypass surgery and graft types</h4><dl class="temp-labeled-list"><dt>16.</dt><dd><p class="no_top_margin">Offer bypass surgery for treating people with severe lifestyle-limiting intermittent claudication only when:</p><ul class="circle"><li class="half_rhythm"><div>angioplasty has been unsuccessful or is unsuitable and</div></li><li class="half_rhythm"><div>imaging has confirmed that bypass surgery is appropriate for the person.</div></li></ul></dd><dt>17.</dt><dd><p class="no_top_margin">Use an autologous vein whenever possible for people with intermittent claudication having infra-inguinal bypass surgery.</p></dd></dl></div><div id="ch4.s18"><h4>4.2.5.4. Naftidrofuryl oxalate</h4><dl class="temp-labeled-list"><dt>18.</dt><dd><p class="no_top_margin">Consider naftidrofuryl oxalate for treating people with intermittent claudication, starting with the least costly preparation, only when:</p><ul class="circle"><li class="half_rhythm"><div>supervised exercise has not led to satisfactory improvement and</div></li><li class="half_rhythm"><div>the person prefers not to be referred for consideration of angioplasty or bypass surgery.</div></li></ul></dd></dl><p>Review progress after 3–6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit.</p></div></div><div id="ch4.s19"><h3>4.2.6. Management of critical limb ischaemia</h3><dl class="temp-labeled-list"><dt>19.</dt><dd><p class="no_top_margin">Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.</p></dd></dl><div id="ch4.s20"><h4>4.2.6.1. Revascularisation</h4><dl class="temp-labeled-list"><dt>20.</dt><dd><p class="no_top_margin">Offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including:</p><ul class="circle"><li class="half_rhythm"><div>comorbidities</div></li><li class="half_rhythm"><div>pattern of disease</div></li><li class="half_rhythm"><div>availability of a vein</div></li><li class="half_rhythm"><div>patient preference.</div></li></ul></dd><dt>21.</dt><dd><p class="no_top_margin">Do not offer primary stent placement for treating people with critical limb ischaemia caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease.</p></dd><dt>22.</dt><dd><p class="no_top_margin">Consider primary stent placement for treating people with critical limb ischaemia caused by complete aorto-iliac occlusion (rather than stenosis).</p></dd><dt>23.</dt><dd><p class="no_top_margin">Use bare metal stents when stenting is used for treating people with critical limb ischaemia.</p></dd><dt>24.</dt><dd><p class="no_top_margin">Use an autologous vein whenever possible for people with critical limb ischaemia having infra-inguinal bypass surgery.</p></dd></dl></div><div id="ch4.s21"><h4>4.2.6.2. Management of critical limb ischaemic pain</h4><dl class="temp-labeled-list"><dt>25.</dt><dd><p class="no_top_margin">Offer paracetamol, and either weak or strong opioids depending on the severity of pain, to people with critical limb ischaemic pain.</p></dd><dt>26.</dt><dd><p class="no_top_margin">Offer drugs such as laxatives and anti-emetics to manage the adverse effects of strong opioids, in line with the person’s needs and preferences.</p></dd><dt>27.</dt><dd><p class="no_top_margin">Refer people with critical limb ischaemic pain to a specialist pain management service if any of the following apply:</p><ul class="circle"><li class="half_rhythm"><div>their pain is not adequately controlled and revascularisation is inappropriate or impossible.</div></li><li class="half_rhythm"><div>ongoing high doses of opioids are required for pain control</div></li><li class="half_rhythm"><div>pain persists after revascularisation or amputation.</div></li></ul></dd><dt>28.</dt><dd><p class="no_top_margin">Do not offer chemical sympathectomy to people with critical limb ischaemic pain, except in the context of a clinical trial.</p></dd></dl></div><div id="ch4.s22"><h4>4.2.6.3. Major amputation</h4><dl class="temp-labeled-list"><dt>29.</dt><dd><p class="no_top_margin">Do not offer major amputation to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team.</p></dd></dl></div></div></div><div id="ch4.s23"><h2 id="_ch4_s23_">4.3. Key research recommendations</h2><ul><li class="half_rhythm"><div>What is the clinical and cost effectiveness of a ‘bypass surgery first’ strategy compared with an ‘angioplasty first’ strategy for treating people with critical limb ischaemia caused by disease of the infra-geniculate (below the knee) arteries?</div></li><li class="half_rhythm"><div>What is the clinical and cost effectiveness of supervised exercise programmes compared with unsupervised exercise for treating people with intermittent claudication, taking into account the effects on long-term outcomes and continuing levels of exercise?</div></li><li class="half_rhythm"><div>What is the effect of people’s attitudes and beliefs about their peripheral arterial disease on the management and outcome of their condition?</div></li><li class="half_rhythm"><div>What is the clinical and cost effectiveness of selective stent placement compared with angioplasty plus primary stent placement for treating people with critical limb ischaemia caused by disease of the infra-geniculate arteries?</div></li><li class="half_rhythm"><div>What is the clinical and cost effectiveness of chemical sympathectomy in comparison with other methods of pain control for managing critical limb ischaemic pain?</div></li></ul></div><div id="bk_toc_contnr"></div></div></div>
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<div xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Views</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PDF_download" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/NBK327460/?report=reader">PubReader</a></li><li><a href="/books/NBK327460/?report=printable">Print View</a></li><li><a data-jig="ncbidialog" href="#_ncbi_dlg_citbx_NBK327460" data-jigconfig="width:400,modal:true">Cite this Page</a><div id="_ncbi_dlg_citbx_NBK327460" style="display:none" title="Cite this Page"><div class="bk_tt">National Clinical Guideline Centre (UK). Lower Limb Peripheral Arterial Disease: Diagnosis and Management [Internet]. London: Royal College of Physicians (UK); 2012 Aug. (NICE Clinical Guidelines, No. 147.) 4, Guideline summary.<span class="bk_cite_avail"></span></div></div></li><li><a href="/books/n/nicecg147/pdf/">PDF version of this title</a> (3.4M)</li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>In this Page</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="page-toc" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="#ch4.s1" ref="log$=inpage&link_id=inpage">Key priorities for implementation</a></li><li><a href="#ch4.s9" ref="log$=inpage&link_id=inpage">Full list of recommendations</a></li><li><a href="#ch4.s23" ref="log$=inpage&link_id=inpage">Key research recommendations</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Other titles in this collection</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="source-links" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/n/nicecollect/">
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National Institute for Health and Clinical Excellence: Guidance
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