{"id":9326,"date":"2011-07-12T07:01:36","date_gmt":"2011-07-12T11:01:36","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=9326"},"modified":"2011-07-19T17:44:13","modified_gmt":"2011-07-19T21:44:13","slug":"pass-up-the-guidelines-please","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/07\/12\/pass-up-the-guidelines-please\/","title":{"rendered":"Pass (Up) the Guidelines, Please"},"content":{"rendered":"

The Occluded Artery Trial (OAT)<\/a> demonstrated no benefit of routine PCI in persistently occluded infarct-related arteries identified more than 24 hours after MI. These results were incorporated into the revised guidelines for STEMI<\/a>, NSTEMI<\/a>, and PCI <\/a>(published in 2007 and 2008) as a class III recommendation (i.e., not indicated and inappropriate). The senior investigator for OAT — and coauthor of the revised STEMI guidelines — now reports <\/a>that the results of OAT have not been incorporated into practice: many patients still undergo late reperfusion (>24 hrs) with PCI of the occluded infarct-related artery despite being asymptomatic and stable.<\/p>\n

Why haven\u2019t the guidelines been implemented?<\/strong><\/em><\/p>\n

Are many physicians unfamiliar with the guidelines?<\/em><\/strong> Possibly. Many busy practitioners find the exhaustive guidelines exhausting to read: excessively long and difficult to navigate.<\/p>\n

More likely, physician and patient barriers play a large role in the inappropriate use of angiography and PCI, as we highlighted in a previous editorial<\/a>. How so?<\/strong><\/em><\/p>\n

    \n
  1. In an era in which invasive cardiac procedures are manifestations of high-technology, resource-intensive medical care, many patients expect and insist on aggressive management. The term \u201cconservative management\u201d may project the impression (to physicians and patients alike) of obsolescence, inadequacy, and inferiority rather than of thoughtful reflection and the application of scientifically based, ischemia-guided therapy.<\/li>\n

    In the event of an adverse outcome, the patient and his or her family may be more understanding and forgiving if an aggressive approach was pursued (i.e., if \u201ceverything possible was done\u201d), even if such an approach contributes, directly or indirectly, to the adverse outcome. <\/em><\/p>\n

  2. Physicians are skeptical about the applicability of the results of trials (and guidelines) to their patients. We refer to these as the \u201cDAM\u201d studies (D<\/strong>oesn\u2019t A<\/strong>pply to M<\/strong>e).<\/li>\n
  3. Studies that substantiate preconceived notions are likely to be embraced and their recommendations followed, whereas those that do not are often ignored.<\/li>\n
  4. The abundance of facilities for prompt angiography and revascularization, physicians trained to perform these procedures, and monetary remuneration to the facilities and physicians encourages the use of angiography and revascularization without a clear indication.<\/li>\n<\/ol>\n

    Do we need more guidelines?<\/strong><\/em> Probably not, since we don\u2019t effectively implement the ones we have.<\/p>\n

    What are your thoughts? How can we more effectively integrate guidelines into clinical practice?<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

    The Occluded Artery Trial (OAT) demonstrated no benefit of routine PCI in persistently occluded infarct-related arteries identified more than 24 hours after MI. These results were incorporated into the revised guidelines for STEMI, NSTEMI, and PCI (published in 2007 and 2008) as a class III recommendation (i.e., not indicated and inappropriate). The senior investigator for […]<\/p>\n","protected":false},"author":214,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[595,903,301],"class_list":["post-9326","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology","tag-guidelines","tag-oat","tag-pci"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/9326","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/214"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=9326"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/9326\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=9326"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=9326"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=9326"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}