LETTERS TO THE EDITOR
Reply
Elliott M. Antman, MD, FACC, FAHA*,
Daniel T. Anbe, MD, FACC, FAHA,
Paul W. Armstrong, MD, FACC, FAHA,
Eric R. Bates, MD, FACC, FAHA,
Lee A. Green, MD, MPH,
Mary Hand, MSPH, RN, FAHA,
Judith S. Hochman, MD, FACC, FAHA,
Harlan M. Krumholz, MD, FACC, FAHA,
Frederick G. Kushner, MD, FACC, FAHA,
Gervasio A. Lamas, MD, FACC,
Charles J. Mullany, MB, MS, FACC,
Joseph P. Ornato, MD, FACC, FAHA,
David L. Pearle, MD, FACC, FAHA,
Michael A. Sloan, MD, FACC and
Sidney C. Smith, Jr., MD, FACC, FAHA
* Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115-6110 (Email: eantman{at}rics.bwh.harvard.edu).
In the 2004 ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) (1,2) we adapted the existing AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update (3) to develop the recommendations for preventive therapy at the time of discharge from the hospital after STEMI. Also included as a reference in the STEMI guidelines are the AHA evidence-based guidelines for cardiovascular disease prevention in women (4), which include several references supporting the benefits of omega-3 fatty acids for patients with coronary heart disease. Each of these statements emphasizes the need for supplementation with omega-3 fatty acids. Inasmuch as the AHA secondary prevention guidelines are now undergoing revision with a projected date of publication in early 2005 and because secondary prevention was not the purview of the STEMI statement, specific recommendations about doses of omega-3 fatty acids were not made as part of the STEMI guideline. The 2003 publication (5) cited by Dr. Colquhoun is an editorial statement from the Nutrition Committee of the AHA and not a formal ACC/AHA guideline. It is expected that omega-3 fatty acids as well as other important dietary measures will receive continued emphasis in the upcoming guidelines on secondary prevention for cardiovascular disease.
Dr. Kessler questions the utility of certain recommendations in the recently published ACC/AHA STEMI guidelines and then makes rather broad statements regarding all cardiovascular guidelines (2). His main point seems to be that self-evident clinical truths are "nonempiric," cannot be experimentally proven, and should not be handled in the recommendation scheme in the same fashion as empiric or evidence-based recommendations. The Task Force on Practice Guidelines for the ACC and AHA recognized the need to account for recommendations that are agreed to represent the best clinical practice but have not been formally tested in large-scale clinical trials—this is handled by the level of evidence component of the recommendation schema. A recommendation that reflects the consensus of a group of experts (members of the writing committees, peer reviewers of the document, and administrative review by the governing bodies of the ACC and AHA) is assigned a Level of Evidence of C.
To make his point, Dr. Kessler cites two examples in the STEMI guideline but unfortunately misquotes the recommendations and fails to represent the spirit and intent of the writing committee accurately. The recommendation about obtaining an electrocardiogram (ECG) centers around the 10-min time frame for obtaining the tracing in the emergency department. Simply obtaining an ECG tracing in a patient with STEMI is inadequate if it is not obtained promptly so that myocardium can be salvaged by reperfusion. In fact, the recommendation in question has actually become a performance measure to track how well health care teams are handling STEMI patients.
The second recommendation questioned by Dr. Kessler relates to coronary angiography. Again he misquotes the recommendation. The Class III recommendation states that coronary angiography should not be performed in patients who are not considered candidates for revascularization. Dr. Kessler claims this means the risk of revascularization outweighs the benefits. Although that is one aspect of what the writing committee had in mind in crafting that recommendation, there were several others. We were concerned that some clinicians recommend that all patients with STEMI undergo coronary angiography before discharge. Such a practice is not cost-effective if there is no intention to perform revascularization because of a perceived unfavorable risk:benefit ratio, an absolute refusal to consider revascularization by the patient, or a limited life expectancy of the patient such that the likelihood of achieving a benefit from revascularization is extremely small. Inappropriate referral for coronary angiography not only increases the cost to the health care system but exposes the patient to risks of the procedure without any potential gain from the information provided.
We believe the recommendation scheme is well understood by clinicians and should remain as published in Table 1 of the STEMI guideline for future guidelines in cardiovascular medicine.
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References
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1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004Available at: www.acc.org/clinical/guidelines/stemi/index.pdf..
2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) Circulation 2004;110:588-636 J Am Coll Cardiol 2004;44:671-719.[Free Full Text]
3. Smith Jr SC, Blair SN, Bonow RO, et al. AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare professionals from the American Heart Association and the American College of Cardiology J Am Coll Cardiol 2001;38:1581-1583.[Free Full Text]
4. Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women Circulation 2004;109:672-693.[Free Full Text]
5. Kris-Etheron PM, Harris WS, Appel LJ, AHA Nutrition Committee. Omega-3 fatty acids and cardiovascular disease New recommendations from the American Heart Association (editorial) Arterioscler Thromb Vasc Biol 2003;23:151-152.[Free Full Text]
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Omega-3 Fatty Acids for Secondary Prevention
- David Colquhoun
J. Am. Coll. Cardiol. 2005 45: 1552.
[Full Text]
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