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European Heart Journal Advance Access originally published online on October 5, 2005
European Heart Journal 2005 26(22):2474-2475; doi:10.1093/eurheartj/ehi561
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Evidence-based vs. ‘impressionist’ medicine: how best to implement guidelines: reply

Jean-Pierre Bassand

Centre Hospitalier Universitaire Jean Minjoz
Boulevard Fleming
Besançon France
Tel: +33 381 66 85 39
Fax: +33 381 66 85 82
E-mail address: jean-pierre.bassand{at}ufc-chu.univ-fcomte.fr

Michal Tendera

3rd Division of Cardiology
Silesian School of Medicine
ul. Ziolowa 47
40-635 Katowice
Poland

Silvia G. Priori

Associate Professor of Cardiology
Department of Cardiology
University of Pavia
Italy
Department of Molecular Cardiology
Salvatore Maugeri Foundation
Pavia
Italy

Drs Fennell and Worrall make interesting and valuable comments on our recent paper,1 which was intended only as an editorial, stressing the wide discrepancy between the recommendations to treat and the actual implementation of guidelines. This lack of implementation can result in loss of benefit for patients who are under treated. The impact of under use of medical therapies or strategies with proven efficacy on immediate and long-term outcome has been amply documented. We based our assumptions on some of the critical areas of our discipline, particularly acute coronary syndromes, where the life of the patient is at stake, and also heart failure. Registries have proven that in the field of acute coronary syndromes, poor compliance with guidelines can result in a two-fold increase in mortality at 1 month and 1 year. It is, therefore, the duty of every physician to implement guidelines, when one is absolutely certain that they will have a positive impact on the life expectancy of the patient.

This said, we understand the concerns of Drs Fennell and Worrall about the involvement of the industry in the development of implementation programmes. From a purely pragmatic point of view, it can be acknowledged that little or no funds are provided by health authorities to promote best practice through implementation programmes for guidelines, although some initiatives supported by health authorities are beginning in Europe.

The most important remark by our colleagues Fennell and Worrall is about the strength of evidence of recommended therapies included in guidelines. They propose that it could be based more on the number needed to treat (NNT), which may reflect the cost effectiveness of a given treatment. This comment is certainly valid, and indeed, NNT and also number needed to harm will be incorporated in a future set of guidelines to be released soon by the European Society of Cardiology, (namely non-ST-segment elevation acute coronary syndromes).

References

  1. Bassand JP, Priori S, Tendera M. Evidence-based vs. ‘impressionist’ medicine: how best to implement guidelines. Eur Heart J 2005;26:1155–1158. Published online ahead of print May 3, 2005.[Abstract/Free Full Text]

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This Article
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26/22/2474-a    most recent
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