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Official guidelines on how to treat heart problems largely based on weak evidence and expert opinion


The number of recommendations in the American Heart Association/American College of Cardiology (AHA/ACC) clinical-practice guidelines have progressively increased over time, but these recommendations are often based on weak evidence and expert opinion, a new study, published in the February 25, 2009 issue of the Journal of the American Medical Association, has shown [1].

"It's a sobering result," lead investigator Dr Pierluigi Tricoci (Duke Clinical Research Institute, Durham, NC) told heartwire. "Almost half of the recommendations have a level of evidence C, meaning they have no supporting evidence or just a little supporting evidence. This means that situations where we are sure of what to do are small in number, while the situations where we are not so sure of what to do are the majority."

In an editorial accompanying the published study [2], Drs Terrence Shaneyfelt and Robert Centor (University of Alabama School of Medicine, Birmingham) write that the "overreliance on expert opinion in guidelines is problematic," particularly since the guideline committees come to the table with implicit biases, values, and goals that aren't typically disclosed. Moreover, too many current guidelines are marketing- and opinion-based pieces, "delivering directive rather than assistive statements," they add

"However, it seems unlikely that substantial change will occur because many guideline developers seem set in their ways," write Shaneyfelt and Centor. "If all that can be produced are biased, minimally applicable consensus statements, perhaps guidelines should be avoided completely. Unless there is evidence of appropriate changes in the guideline process, clinicians and policy makers must reject calls for adherence to guidelines."

Speaking with heartwire, Tricoci, rather than fault the guideline committees, said the findings represent a failure of the current research system. With clinical trials performed predominantly by industry, unaddressed clinical questions are overlooked, as these companies are interested primarily in bringing new products to market.


http://www.theheart....ticle/944039.do