Get With the Guidelines: A New Chapter?

For more than 25 years, the American College of Cardiology (ACC) and the American Heart Association (AHA) have collaborated on clinical practice guidelines in an effort to improve the quality of care in this country. Studies in the early 1990s showed that the medical therapy recommended by the guidelines was frequently not followed. Both organizations initiated programs to improve the implementation of guidelines, which focused on medical therapy in patients with known coronary artery disease, acute coronary syndromes, and congestive heart failure. However, there have been relatively little data regarding the implementation of guideline recommendations for revascularization.1Article see p 267 In this issue of Circulation , Hannan et al2 have completed an important study on that subject. Using the resources of the New York State Cardiac Diagnostic Catheterization database, the authors examined the recommendations for revascularization made by the catheterization laboratory cardiologist in 10,333 patients for whom that physician was the final source of the recommendation. Their findings suggest that 94% of patients for whom percutaneous coronary intervention (PCI) was indicated by the guidelines were recommended for PCI, and that 93% of patients for whom either bypass surgery (CABG) or PCI was indicated by the guidelines were recommended for PCI. A more controversial finding from this study relates to patients for whom the ACC/AHA guidelines indicated CABG, inasmuch as only 53% of these patients were recommended for CABG by the catheterization laboratory cardiologist, and 34% of these patients were recommended for PCI. Of patients for whom neither CABG nor PCI was indicated by the guidelines, 6% were recommended for CABG, and 21% were recommended for PCI.Before we accept or interpret these findings, we must carefully review the authors’ methodology and the fundamental general limitations of guidelines. As the authors indicate, it is not easy to apply …