'Noise' Counterproductive to New CV Risk/Cholesterol Guidelines: Editorial

January 29, 2014

BALTIMORE, MD — Now that the dust is settling, a sober editorial suggests the "outrage," "attacks," and "noise" that surrounded the very public rollout of the new American College of Cardiology/American Heart Association (ACC/AHA) clinical guidelines for risk assessment and cholesterol treatment likely left patients and clinicians confused and distrustful of the new recommendations[1].

In the editorial, published online January 24, 2014 in the Annals of Internal Medicine, Dr Eliseo Guallar (Johns Hopkins Bloomberg School of Public Health) and Dr Christine Laine (American College of Physicians, Philadelphia, PA), the editor in chief of Annals, say that if the "goal is high-value healthcare for all, we must quiet the noise that accompanies guidelines so that we can hear the evidence speak."

For the past two months, there has been no shortage of opinions about the new guidelines. While some have said they will not use the new cholesterol and prevention guidelines, others have said they are getting accustomed to the new recommendations. A high-profile editorial in the New York Times by Dr John Abramson (Harvard Medical School, Boston, MA) and Dr Rita Redberg (University of California, San Francisco) had criticized the guidelines and urged physicians not to give statins to more patients, which they said would be the result of the new ACC/AHA recommendations.

As reported by heartwire , the new cholesterol guidelines, which were developed in conjunction with the National Heart, Lung, and Blood Institute (NHLBI), made a massive splash when they were presented just days before the AHA 2013 Scientific Sessions in Dallas, TX. The cholesterol guidelines were a radical departure from previous iterations, most notably in their abandonment of LDL-cholesterol targets. The expert panel stated there was simply no evidence from randomized, controlled clinical trials to support treatment to a specific target.

Such an abrupt change from previous guidelines, where physicians were recommended to treat to less than 100 mg/dL or to less than 70 mg/dL in high-risk patients, can generate particularly intense outrage, according to the editorialists. While some debate about the guidelines should be expected, generalizing clinical-trial results to different settings will always require some degree of subjectivity and personal interpretation.

"Although some controversies over guideline recommendations are intellectually justified by the complexity of the task and the limitations of available evidence, social and emotional factors often needlessly magnify controversies," write Guallar and Laine. "The ACC/AHA cholesterol guidelines landed in a perfect storm created by the release of the documents a few days before a high-profile meeting and media stories that sensationalized disagreements among stakeholders."

They add that the 24/7 news cycle magnified the disagreements, provoked adversarial debate, and allowed those left out of the guideline process an opportunity to attract attention to their positions.

Limiting the Noise

To counter the hype and hoopla, Guallar and Laine say the inclusion of multiple stakeholders during the writing process can limit postrelease criticism. In addition, limiting recommendations to formal evidence that has been rigorously peer reviewed can also mitigate some of the distraction. They add that the ACC/AHA likely invited criticism given that the risk calculator was new and not available for public scrutiny prior to the release of the guidelines.

As heartwire has reported, other researchers testing the risk calculator have criticized it for overestimating the 10-year risk of cardiovascular events. This led to a hastily convened press conference at the AHA meeting, with the expert panel compelled to explain the reasoning for selecting the patient populations included in the risk model and why the calculator might overestimate risk in some patients.

As for their final suggestion, the editorialists place responsibility on the shoulders of the medical societies and medical reporters.

"Professional organizations should refrain from turning the release of new or updated guidelines into media events, and the media should refrain from turning the scientific debate that surrounds guidelines into stories of professional strife and disregard for patients," write Guallar and Laine.

Guallar and Laine report no conflicts of interest.

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