| Popis: |
present an excellent summation of the 2002 American Collegeof Cardiology (ACC)/American Heart Association (AHA)guidelines for the initial management of patients with non–ST-segment elevation acute coronary syndromes. However, it isconcerning that clinicians (and unfortunately lawyers) mayequate some of the ‘‘class I’’ therapy recommendations for the‘‘emergency department (ED) management’’ of acute coronarysyndrome patients presented in this article with an established‘‘standard of care’’ that is evidence based, which is not the case.To put the ACC/AHA summary document in perspective, itis necessary to briefly review the methodology used ingenerating its recommendations. In the past, managementrecommendations were often developed that were basedprimarily on expert opinion and generally accepted as gospeleven when there was no, or limited, supporting evidence. Thelimitations of this approach have been recognized by thescientific community as potentially perpetuating not onlymisinformation but at times even dangerous actions. Examplesof the pitfalls implicit to consensus recommendations aboundand include the use of calcium in the management of ventricularfibrillation, digoxin in acute decompensated heart failure,theophylline in acute asthma, military antishock trousers inhypotensive trauma patients, and hyperventilation in themanagement of severe traumatic brain injury. These are alltreatments once supported by the experts and that have sincebeen shown to either be of no benefit or dangerous. Withrecognition of the potential dangers inherent to consensusrecommendations, evidence-based methodology requires thatstrong recommendations be based on the presence of strongevidence (ie, well-designed research that specifically addressesthe question being asked). In other words, in therapeutics, thehighest-level recommendations (levels ‘‘A,’’ ‘‘I,’’ ‘‘standard’’)require supporting evidence from randomized double-blindplacebo-controlled studies with little or no bias. Consequently,there are few ‘‘level I,’’ ‘‘level A,’’ or ‘‘standard’’recommendations in evidence-based literature. Most guidelinemethodologies do not allow opinion to drive a high-levelrecommendation no matter how strong a consensus exists withthe experts; without evidence, nothing higher than the lowestlevel (level ‘‘III,’’ ‘‘C,’’ or ‘‘option’’) recommendation can bemade. |
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