CURRENT CARDIOLOGY PRACTICE: EVIDENCE OR EXPERIENCE BASED ? AN ANALYSIS OF ACC/AHA GUIDELINES.
S. Venkatesan, Madras Medical College. Chennai
If a major therapeutic procedure is adviced based on simply by experience or expert opinion how can we say evidence based medicine is practiced !
Evidence based cardiology is the buzz word in global cardiovascular health care organizations. All diagnostic and therapeutic interventions are undergoing rigorous randomized trials for proof of efficacy and safety. 
ACC/AHA have published management guidelines and it has been accepted as de-facto standard of clinical cardiology practice world wide. In these guidelines class 1 indication is defined as Conditions for which there is evidence for and/or general agreement that the procedure is useful and effective. These indications are supported by three levels of evidence.(A,B,C) .It has been observed, many of the recommendations in class 1 were supported by only level C evidence. (Expert consensus or agreement ). We analysed how much of todays guidelines is agreement based and how much is evidence based. The latest practice guidelines of ACC/AHA for Acute myocardial infarction , Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction , chronic stable angina ,coronary angiography were analysed. The no of class 1 indications were counted in each set of guidelines and each of the indication were sub grouped with reference to the levels of evidence to which it was supported. There were a total of 210 class 1 indications.
|
|
Class 1 Level A |
Class 1 Level B |
Class 1 Level C |
P value 1A vs 1C |
|
AMI(54) |
7 |
25 |
22 |
<.0001 |
|
UA (66) |
11 |
26 |
29 |
<.0001 |
|
CSA(59) |
8 |
29 |
22 |
<.0001 |
|
CAG(31) |
3 |
12 |
16 |
<.0001 |
|
Total(210) |
29(13.9%) |
92(43.8%) |
89(42.4%) |
<.001 |
13.9% of class 1 indications were based on level A evidence. 42.4% of class 1 indication were based on Level C ( agreement of experts).Though evidence based cardiology is considered to define the standards in Cardiology practice in reality we lack evidence in most of the situations.
We conclude that consensus or agreement based cardiology practice is the dominant theme in current ACC/AHA
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