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Adequacy of Reporting Monitoring Regimens of Risk Factors for Cardiovascular Disease in Clinical Guidelines: Systematic Review
Study Questions:
Do clinical guidelines make appropriate monitoring recommendations for prevention and treatment of cardiovascular disease?
Methods:
The authors reviewed published guidelines for the three major risk factors for cardiovascular disease: cholesterol level, smoking, and hypertension. The primary outcome of this report was the frequency with which the guidelines dealt with monitoring of risk factors. Secondary outcomes were completeness of monitoring recommendations, defined by the presence of what to monitor, when to monitor, what to do if the targets or variables were not met, and the reported level or strength of the evidence.
Results:
A total of 117 guidelines were identified, 84 (72%) of which contained a section on lipids. Of those guidelines with a section on lipids, 53% (n = 44) provided no information or specific recommendations on what to monitor, 51% (n = 43) provided no information on when to monitor, and 64% (n = 54) provided no guidance on what to do if the target was out of range. Guidelines for hypertension (n = 79) and smoking (n = 65) were little better, with 63% (n = 50) and 54% (n = 35), respectively, providing no recommendation for what to monitor. The number of guidelines that explicitly referenced the level of evidence for monitoring was low, with most of the recommendations based on weak levels of evidence.
Conclusions:
The authors concluded that many guidelines for cardiovascular disease do not report clearly what to monitor and what to do if a change is detected. If no evidence is available to support a specific monitoring schedule, this should be explicit in the guideline, with a description of the new research that would fill the gap.
Perspective:
The conclusions are consistent with my experience in reading cardiovascular disease prevention and treatment guidelines. Among the 117 references were two references from my own institution (diabetes and coronary disease), which were written with great pains so as to be inclusive but evidence based. Clearly, there are sparse data from the evidence that help experts write guidelines on monitoring frequency and response to abnormal values. There are considerable clinical and cost implications of these types of recommendations, and very little agreement between expert generalists and specialists looking at the same data from different clinical experiences.
Keywords: Lipids, Cardiovascular Diseases, Coronary Disease, Risk Factors, Hypertension
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