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.

 

 

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.