The Evolution and Future of ACC/AHA Clinical Practice Guidelines: A 30-Year Journey: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Perspective:

The following are 10 points to remember about the evolution and future of American College of Cardiology (ACC)/American Heart Association (AHA) clinical practice guidelines (CPGs):

1. CPGs are statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative care options.

2. The first CPG was undertaken in response to the US government’s request to review the evidence concerning cardiac pacemakers and develop CPGs to mitigate potential overuse.

3. The validity and reliability of CPGs have been questioned, based on concerns that the CPGs are composed by individuals with perceived conflicts of interest, primarily due to relationships with industry (RWI) engaged in the development or marketing of medical technology or pharmaceutical agents. Management of RWI involves selection of a balanced guideline writing committee (GWC), and requires that both the chair and a majority of members have no relevant RWI.

4. More than 90% of cardiologists found the ACC/AHA CPGs routinely useful in clinical practice. In fact, >80% of cardiologists apply CPGs in managing patients in most circumstances. The CPG features found most useful are clinical applicability and authority, brevity and clarity, comprehensiveness, ease of access and use, and currency.

5. For cardiovascular or multispecialty practice clinicians, the most frequent use of CPGs is to address a specific clinical question at the point of care, such as in the office, in the hospital, or on rounds. For cardiologists in medical schools and universities, CPGs are most commonly used as a teaching tool.

6. The Institute of Medicine recommendation to have CPGs informed by the highest-quality (i.e., randomized clinical trial) evidence and meta-analyses, assessed by an independent evidence review committee, may seem to be discordant with the views and needs of these CPG users, that is, to include not only strong evidence-based recommendations, but also those based on lesser evidence and expert opinion and to do so in a timely, concise, and accessible way. This dilemma presents an ongoing and major challenge to the Task Force in charting the future course for CPGs.

7. The AHA scientific statements and the ACC clinical expert consensus documents represent another important educational product ancillary to CPGs. These documents provide expert opinion and evidence summaries on important focused cardiovascular topics too narrow or immature to warrant a full CPG, but for which there is significant scientific and clinical interest.

8. Looking to the future, it is clear that the ACC/AHA CPG methodology will evolve in response to a changing health care environment and the availability of new formats with which to deliver recommendations. Creation of ongoing ‘living’ documents is under development on various digital platforms.

9. Although past GWCs have excluded cost considerations from recommendations, it is clear that with limited health care resources and rising costs, it is important and appropriate to consider cost, cost-effectiveness, and value.

10. To maintain consistency and facilitate implementation of CPG recommendations, it is important to harmonize ACC/AHA CPGs with those issued by other organizations within the United States and abroad. Notwithstanding differences in resources, economy, RWI policies, and availability of guideline-directed medical therapies, harmonization across CPGs has the potential to minimize confusion in the caregiver community and enhance adherence to recommendations.

Keywords: Government, Reproducibility of Results, Patient Care, Expert Testimony, Schools, Medical, Universities, Marketing, Advisory Committees, Institute of Medicine (U.S.), Consensus, Caregivers


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