Some two decades ago, we, the cardiology community started writing guidelines, recommendations, protocols, whatever you call it, in managing specific clinical problems in cardiology. In this model, there is a class of recommendation supported by different level of evidence. This concept looked perfectly scientific, futuristic, and grew so well .It has been considered the de facto standard of practice.(Still it is) A few years ago, these guidelines were made more attractive and user-friendly by color-coding these guidelines.as green, yellow, orange, and red, akin to traffic signals.
In the same decades, as we glorified these guidelines, the rate of inappropriate intervention parallelly raised. Every global forum talk about reducing unnecessary treatments, and improving the cost-effectiveness. It is explicitly clear the purpose of these glorified guidelines in the last 20 years were spectacularly defeated.
When we think for few moments, who or what could be the culprit ? , one can realize easily the same guidelines turned out to be the culprits, by giving a room and liberty to cardiologists to drive through cath lab, crossing the yellow and orange signals . In my perception, very few cardiologists thinks 2B is a relative contraindication. and 2A is just a shot of chance. Why then ?, they should get a prime place in the recommendation chart. How many of us realize, these complex guidelines (? inadvertently) acts as a “temptation amplifier” to many ,energetic skilled, go get it, cardiologists.
A reality check
Many of my colleagues find no wrong in doing other than class 1 Indication . They justify it by saying they offer the benefit of doubt (or as off label usage) to their patients. No one talks about harm that comes out of same doubting. Right now, when we analyzed( mostly reliable personal info sharing) up to 50-75% procedures in cath lab are done by physicians who cross either orange, yellow, or even red signals. Fortunately or unfortunately , there is no officers on cath lab highways to give a ticket or to capture evidence. Only our conscience remain the CCTV.
A 10 second animated solution to a vexing ethical dysfunction in cardiology
Final message
What shall be done to improve the appropriateness of the treatment Interventions ?
There is a simple solution is readily available, but I am sure it is never going to happen .
“Like any walk of life a hidden culprits are easy to catch, but it is so difficult if is seen right in front of you”
Let ACC, ESC, SCAI, HRS, & CSI all sit together and debate to get rid of all those confusing and contaminating clutter in the guidelines, and retain only the class 1 and possibly Class 2A .
Counterpoint
Guidelines are written with a clear application of mind ,taking into account of available evidence and growing science, Hence indications are dynamic. Class 2B can become Class 1 , While even a Class 1 can become a Class 3. So we have to take a chance and live with it. May be some truth in it. But the issue is beyond this . We know, as of now there is no true restrictions in spite of the guidelines. It is a secret truth a huge number of late PCIs, CTOs, Mitra clips, LAA devices, AF ablations are performed under the Orange -red border zone.
Dr.S.Venkatesan MD 