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VIEWPOINT AND COMMENTARY

Clinical Guidelines and Practice

In Search of the Truth

Dean J. Kereiakes, MD, FACC^1,_*,_* and Elliott M. Antman, MD, FACC

^_* Heart Center of Greater Cincinnati and the Lindner Center at the Christ Hospital, Cincinnati, Ohio
Brigham and Women’s Hospital, Boston, Massachusetts

Manuscript received January 18, 2006; revised manuscript received March 23, 2006, accepted March 30, 2006.

^_* Reprint requests and correspondence: Dr. Dean J. Kereiakes, The Lindner Center, 2123 Auburn Avenue, Suite 424, Cincinnati, Ohio 45219. (Email: lindner{at}fuse.net).

Data from randomized clinical trials, non-randomized studies, and registries, as well as expert panel consensus are appropriately weighted and woven into the context of clinical practice guidelines. Recent guidelines for the care of patients with ischemic heart disease have emphasized both risk stratification and early coronary angiography with revascularization of patients with high-risk indicators. Advances in our understanding of the pathogenesis of acute coronary syndromes and the dynamics of therapeutic innovation (improvement in catheter-based technologies and adjunctive pharmacotherapy) mandate the timely update and revision of practice guidelines. We believe that the weight of evidence remains clearly in support of an early invasive treatment strategy based on risk stratification. Arguments regarding treatment strategy (invasive vs. conservative) are misguided, and greater focus should be placed on improving the treatment-risk paradox demonstrated in clinical practice as well as on strategies to enhance current guideline compliance and utilization. Interest exists in establishing regional centers of excellence for care of patients with acute ischemic heart disease, analogous to the regionalized approach already established for patients with trauma or stroke. This approach is supported by data that demonstrate an inverse relationship between both institutional and operator procedural volumes and mortality, as well as by existing constraints in resources such as specialized nurses and subspecialty-trained physicians. It is appropriate at this time to briefly review specific aspects of the American College of Cardiology/American Heart Association practice guidelines and the current process of care for acute ischemic heart disease.

Abbreviations and Acronyms   ACC = American College of Cardiology   ACS = acute coronary syndrome   AHA = American Heart Association   CPG = clinical practice guideline   DES = drug-eluting stents   ECG = electrocardiogram   GPI = glycoprotein IIb/IIIa inhibitor   MI = myocardial infarction   NSTEACS = non–ST-segment elevation acute coronary syndrome   RCT = randomized clinical trial   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction