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.