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Clinical Guidelines and Practice

In Search of the Truth

Dean J. Kereiakes, MD, FACC^_*,_* 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

View larger version (13K): [in a new window]   Figure 1 Randomized controlled trials of invasive versus conservative treatment strategies for unstable angina and non–ST-segment elevation myocardial infarction. The "weight" of evidence favors the invasive strategy. (Adapted from Cannon CP, et al. Circulation 2003;107:2640.)

View larger version (15K): [in a new window]   Figure 2 Link between American College of Cardiology/American Heart Association guideline adherence (hospital composite quality quartiles) and in-hospital mortality. Every 10% increase in guideline adherence was associated with a 10% reduction in in-hospital mortality (adapted from Peterson et al. [31]). *Adjusted for age, gender, body mass index, race, insurance status, family history of coronary disease, hypertension, diabetes, smoking, hypercholesterolemia, prior myocardial infarction/percutaneous coronary intervention/coronary bypass surgery/congestive heart failure/stroke, renal insufficiency, blood pressure, heart rate, ST-segment shift, and positive cardiac biomarkers.

View larger version (11K): [in a new window]   Figure 3 Combination evidence-based therapies reduce mortality to 1 year following myocardial infarction independent of renal function. Patients receiving multiple clinical practice guideline-adherent medications (antiplatelet agents, beta-blockers, lipid-lowering agents, angiotensin-converting enzyme inhibitors) enjoy incremental survival benefit. Adapted from Tay et al. (62). GFR = glomerular filtration rate; CI = confidence interval.