should we trust and follow evidence based guidelines?

Guidelines authored by Medical bodies like American Heart Association are strongly followed in our cardiology practise in India as there is lack of trial data conducted in India. I as a practising cardiologist strongly advocate Guideline based therapy. 

However, lately I have been surprised by the recommendations of the new guidelines on various topics. This is because of the change in recommendations which are totally contrary to the previous version of the guidelines. 

Let me cite some examples:

  1. The ATP-3 guidelines strongly advocated Goal based therapy for LDL-cholesterol management. They suggested that LDL cholesterol should be maintained below 100 mg/dl in patients with diabetes  or coronary artery disease. These recommendations were followed by Cardiologists all over the world for the last 12-13 years. However, the new guidelines on Lipid management released by the ACC 2014 mentions that there is no trial to suggest that the target-based therapy of LDL cholesterol works. Instead they advocate high dose statin to be given in patients with high risks and to bring down the LDL cholesterol levels by 50%. This is a drastic change which then calls into question the data on which the earlier ATP guidelines were based.

2.  Beta-blockers were advocated in earlier version of guidelines for treatment of Vasovagal syncope. Even, in my personal experience I have number of patients who felt better with beta-blockers and had remission in their symptoms. However, the new guidelines mentions beta-blockers as Class III (harmful).

3. Amiodarone was advocated earlier for acute treatment of  recurrent ventricular tachycardia (VT). However the new European guidelines on Arrhythmias in ACS mentions that it should be avoided and instead Cardioversion should be preferred.

 

The drastic change in the new recommendations/ guidelines  for treatment of the various disorders (as mentioned above in examples) is unexpected and surprising. The reasons for these may be availability of new trial data or not a thorough evaluation of the trials by earlier committees.

Whatever the reasons, for us as practising Clinicians, patient safety is paramount. Thus, Strict adherence to the new guidelines is advisable and to be followed (till the time we have data available from trials conducted in India on Indian patients). However the therapy should be discussed with and individualised for each patient.

 

 

Leisure Jogging Associated With Lowest Mortality Risk!

 

The optimal frequency of jogging in terms of mortality risk was shown to be two to three times a week and at a leisurely pace, according to a study published Feb. 2 in the Journal of the American College of Cardiology (JACC). Jogging three times or more a week was not shown to be statistically different from remaining sedentary.

 

Using data from the Copenhagen City Heart Study, researchers observed the pace, quality and frequency of jogging in 1,098 healthy joggers and 3,950 healthy non-joggers to evaluate the association between jogging and long-term, all-cause mortality. Participants were excluded for a history of coronary heart disease (CHD), stroke and cancer. Participants rated their physical activity on a graded scale of one to four: one, almost entirely sedentary; two: light physical activity 2-4 hours per week; three: vigorous activity for 2-4 hours per week, or light physical activity for more than four hours per week; four: high vigorous physical activity for more than four hours. Joggers were further divided into three subgroups based on dose of jogging: slow (5 mph, 7 mph, >4 hours per week, >3 times per week).

Follow-up of all participants occurred from their first examination in 2001 until 2013, or death (a 12 year followup!).

The results of the study showed that jogging from 1 to 2.4 hours per week was associated with the lowest mortality, while greater quantities of jogging were not significantly different from remaining sedentary in terms of mortality risk. Further, researchers found a U-shaped association between jogging and mortality. Researchers reported 28 deaths among joggers and 128 among sedentary non-joggers, though no causes were recorded.

The authors conclude that “the U-shaped association suggests the existence of an upper limit for exercise dosing that is optimal for health benefits…If the goal is to decrease the risk of death and improve life expectancy, going for a leisurely job a few times per week at a moderate pace is a good strategy.”

In an accompanying editorial comment, Duck-chul Lee, PhD, Department of Kinesiology, College of Human Sciences, Iowa State University, adds that the study “adds to the current body of evidence on the dose-response relationship between running and mortality. However, further exploration is clearly warranted regarding whether there is an optimal amount of running for mortality benefits, especially for cardiovascular and CHD mortality. In addition, because self-reported doses of running may induce measurement error and bias, it would be preferable to use an objective assessment of doses of running in future studies.”

Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC, remarks that “this study attempts to answer the question about whether increased intensity among better trained individuals results in improved outcomes. What is most interesting in this paper is the U-shaped curve of the findings, indicating that moderate exercise, with regard to total duration, frequency and intensity, results in the best benefit. Thus, it was fascinating to see that both the sedentary population and the aggressive exercisers (with regard to frequency, duration and speed) have higher mortality rates than the moderate exercisers.”

 

So, slow down a little if you are jogging too fast and too much! Soak in the surrounding and enjoy the jog at a leisurely pace!

 

 

via Study Shows Leisure Jogging Associated With Lowest Mortality Risk | ACC News Story – American College of Cardiology.

Guidelines for Treating Overweight and Obesity.

The recently released “2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults” was created to reflect the latest research to outline best practices when it comes to treating obesity—a condition that affects more than one-third of American adults.

These guidelines help address questions like “What’s the best way to lose weight?” and “When is bariatric surgery appropriate?”.

Here is what every patient should know about the treatment of overweight and obesity:

Definition of obesity:

Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one’s health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

Benefits of weight loss:

Obesity increases risk for serious conditions such as heart disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3–5% of body weight can improve blood pressure and cholesterol levels and reduce risk for heart disease and diabetes. Ideally, doctors recommend 5–10% weight loss for obese adults, which can produce even greater health benefits.

Weight loss strategies:

There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient’s preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

Bariatric Surgery:

Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI>40) or in patients that have a BMI>35, in addition to a chronic health condition.

 

via Guidelines for Treating Overweight and Obesity.

New Cholesterol Guidelines Abandon LDL Targets!

 

The American College of Cardiology (ACC) and American Heart Association (AHA), in conjunction with the National Heart, Lung, and Blood Institute (NHLBI), have developed and released Guidelines for Cholesterol Control after 9 years of the release of the last version. 

And they contain some substantial changes!

Gone are the recommended LDL- and non-HDL–cholesterol targets, specifically those that ask physicians to treat patients with cardiovascular disease to less than 100 mg/dL or the optional goal of less than 70 mg/dL.

According to the expert panel, there is simply no evidence from clinical trials to support treatment to a specific target. As a result, the new guidelines make no recommendations for specific LDL-cholesterol or non-HDL targets for the primary and secondary prevention of atherosclerotic cardiovascular disease.

Instead, the new guidelines identify four groups of  patients in whom physicians should focus their efforts to reduce cardiovascular disease events. And in these four patient groups, the new guidelines make recommendations regarding the appropriate “intensity” of statin therapy in order to achieve relative reductions in LDL cholesterol.

 

The Four Major Statin Groups

The four major patient groups who should be treated with statins were identified on the basis of randomized, controlled clinical trials showing that the benefit of treatment outweighed the risk of adverse events. The four treatment groups include:

1. Individuals with clinical atherosclerotic cardiovascular disease.

2. Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.

3. Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.

4. Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%.

 

In those with atherosclerotic cardiovascular disease, high-intensity statin therapy—such as rosuvastatin (Crestor, AstraZeneca) 20 to 40 mg or atorvastatin 80 mg—should be used to achieve at least a 50% reduction in LDL cholesterol unless otherwise contraindicated or when statin-associated adverse events are present. In other settings a  moderate reduction of LDL-cholesterol may be aimed for.

The guidelines advise not to aim to achieve a target value of LDL-cholesterol in these patients subsets but advice to start statins in moderate or high intensity to achieve significant reductions in LDL cholesterol from their baseline levels.

 

via New Cholesterol Guidelines Abandon LDL Targets.

Who benefits from anti-cholesterol drugs (Statins): 2013 Guidelines by ACC.

Who benefits from anti-cholesterol drugs (Statins): 2013 Guidelines by ACC.

The new ACC/ American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults focuses on the use of statins for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in higher risk patients. Here are 5 key points you should know about the recommendations.

New Guidelines on Cholesterol management released!

American College of Cardiology (ACC)/American Heart Association (AHA) released new Guidelines on the Treatment of Blood Cholesterol last week.

The biggest change in the new guidelines is : “there is no target level of cholesterol to be achieved by the drugs.”  Lower levels of cholesterol are better but no particular level is found to be protective. So, the following are no longer considered appropriate strategies: treat to target, lower is best, treat to level of cardiovascular disease risk, and based upon lifetime risk of cardiovascular disease. 


Through a rigorous process, four groups of individuals were identified, who would benefit the most with anti-cholesterol drugs called Statins.

Four Statin Benefit Groups: 

• 1) Individuals with clinical atherosclerotic disease: coronary artery disease, stroke, or any vascular disease.

• 2) Individuals with elevations of low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl. 

• 3) Individuals 40-75 years of age with diabetes, and LDL-C > 70 mg/dl.

• 4) Individuals who have an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5% or higher. 

Individuals in the fourth group can be identified by using the new Pooled Cohort Equations for ASCVD risk prediction, developed by the Risk Assessment Work Group. The 10 year- Cardiovascular Risk Calculator can be calculated by entering your values in the calculator which can be downloaded from the below mentioned site.

http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp

The dose of statin advised is either high or moderate in order to reduce LDL cholesterol level by > 50% and 30-50% respectively

Lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies. 



CardioSource – 2013 ACC AHA Guideline on the Treatment of Blood Cholesterol.