Societies mark 30 years of guidelines for evidence-based cardiovascular care


Marking the 30th anniversary of the publication of their first joint guidelines for the diagnosis and treatment of heart disease, the American College of Cardiology and the American Heart Association have published an extensive review of the process and methodology for evaluating cardiovascular research and writing practice guidelines for clinicians.

The Evolution and Future of ACC/AHA Clinical Practice Guidelines: A 30-Year Journey describes the history of the guideline development processes and identifies changes to keep up with rapid developments in medical research as well as technological advances that impact how busy clinicians access information. Changes in the guideline development process include the addition of a separate process for conducting systematic reviews of research, the use of critical questions to focus the evidence review process, the addition of a lay representative on writing committees, the expansion of the peer review process, and an accelerated public release of the manuscripts.

“The Task Force on Practice Guidelines carefully reviewed the guideline process and methods to ensure that future guidelines are current, relevant, and useful at the point of care to busy clinicians,” says Alice Jacobs, immediate past chair of the ACC/AHA Task Force on Practice Guidelines and chair of the ACC/AHA Methodology Summit held to discuss these changes and others proposed by the Institute of Medicine. “ACC/AHA guidelines have provided clinicians with evidence-based decision support for many decades. This document will provide a roadmap to ensure the guideline writing process embraces the rapid evolution of medical research and the equally rapid changes in technology for accessing guidelines.”

The first ACC/AHA guideline, evaluating evidence about cardiac pacemakers, was published in 1984. Over the years, the organisations have developed and updated clinical practice guidelines on 23 different topics from acute coronary syndromes to congenital heart disease and vascular medicine. Through the work of volunteer writing committees, the ACC and AHA also create supporting materials such as pocket guides and quality management products derived from guidelines, including performance measures and appropriate use criteria.

Looking ahead, future guidelines will be more nimble “living” documents published on various digital platforms that allow for more frequent modular updates as evidence evolves. The vision is for guideline recommendations to be embedded within electronic medical record systems and mobile devices that will be accessible at the point of care. The document also recommends that future guidelines address the cost effectiveness of treatments and provide a more integrated approach to treatment for comorbidities; and it foresees increased harmonisation of guidelines with other organisations in the United States and abroad to minimise confusion and enhance adherence to recommendations.

“Clinical Practice Guidelines are at the core of the work of the American College of Cardiology and the American Heart Association,” says Jeffrey L Anderson, current chair of the ACC/AHA Task Force on Practice Guidelines. “With this document, we are establishing a vision to maintain a commitment to evidence-based care while recognising the realities of rapid advances in research and technology and constantly increasing demands on physicians’ time.”

The new document outlines an updated process for managing and monitoring potential bias among guideline writing committee members that goes beyond relationships with industry. Potential biases that may be relevant to the writing effort can include academic setting, race, gender, geography, intellectual stance or scope of clinical practice. The guideline process relies on the principles of “define, disclose, and manage” for addressing potential bias, recognising that sometimes participants with relationships with industry can be the most knowledgeable on given issues. Relationships with industry are reported upon appointment to the writing committees, at the start of all meetings of the committees, and in the final written report. All the writing committee chairs and a majority of each committee’s members must be free of relevant relationships with industry in the previous year and throughout the guideline development process.