Moving Targets, Changing Goals



Dr. Saturnino P. Javier is an interventional cardiologist at Makati Medical Center and Asian Hospital and Medical Center. He is a past president of the Philippine Heart Association (PHA) and past editor of PHA’s Newsbriefs

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Coming one after the other in the last few years, there have been major paradigm changes and revised numerical targets propounded in several treatment recommendations and guidelines for cardiovascular diseases. New goals and revised thresholds have defined the algorithms for hypertension, dietary instructions, cholesterol lowering and pre-diabetes, among others.

Essentially, the scenarios have become such that what used to be clinically acceptable will now have to medically treatable. What used to be objectionable may now be tolerable. What used to be viewed as not a reason for harm is now considered cause for alarm.

The impact of such changes becomes more felt when national and international lay media pick up the medical information and turn them into banner headlines or breaking news which eventually permeate the society at large. The realm of the shifting boundaries encroaches on all aspects of cardiovascular care – (“Cholesterol in the diet is no longer a concern” , “Saturated fat is good” , “BP of 130/80 mm Hg is hypertension” , among others.) If they may seem confusing to some healthcare providers or practitioners, one can imagine the impact on the general public as well.

International medical societies—particularly European and North American physician groups–remain at the forefront of these guideline formulations. Composed of experts and opinion leaders who are armed with all available extensive research trial data, clinical expertise and statistical tools, these groups lead these consensus-gathering initiatives. For example, the writing groups designated by the American Heart Association (AHA) and the American College of Cardiology spent nearly three years and reviewed more than 1,000 clinical studies to formulate the recent guidelines on hypertension diagnosis and management.

Since many of the world’s medical associations derive guidance and programs from these groups, they must certainly be aware of the impact and influence they exert on the world’s

healthcare policies and practices. Understandably, the burden of responsibility resting on the shoulders of these writing groups and task forces must be so immense that considerable delay in the public release of such vital recommendations frequently occurs–especially if those will refute or negate previously set norms. Oftentimes, controversial recommendations are met with considerable negative, or even hostile, reactions. After all, such recommendations do not impact only on professional practice and prescribing habits. They may also influence medical coverage, insurance premiums, reimbursements and government subsidies. Again, as an example, when the new guidelines for hypertension were released at the recent AHA scientific meeting this year, which effectively categorized a blood pressure of 130/80 mm Hg as Stage 1 Hypertension, they effectively made nearly half of the US population (around 46 percent) hypertensive. One can imagine the impact of this new threshold on US resources and physician prescriptions – not to mention the anxieties and frayed nerves among patients who hear those pronouncements on cable news and network broadcasts.

What medical communities should always keep in mind is that the need to revisit and revise guidelines is a constant effort which ensures that new information, developments and discoveries are integrated onto mainstream clinical practice. When new data emerge to nullify previously known or established notions, when new trends supplant previously documented statistical trends, or when startling new discoveries dispute long-held perceptions, then new statements ought to be made via official recommendations, advisories, scientific updates or policy rejoinders – to ensure that better patient care through more effective health promotion and disease prevention is achieved.

Furthermore, it is always wise to remember that, as has been previously emphasized, guidelines are purely recommendatory, and that they should not supersede the physician’s better judgment and thinking. Every decision that comes out of a physician’s clinic by way of a tangible measure –like a prescription, a laboratory request, a referral note, even a free drug sample – is borne out of a laborious and profound analysis that integrates all aspects of a patient’s clinical profile on hand. Such will include the patient’s history and physical examination, relevant co-morbidities, the results of laboratory tests, the inputs of other physicians – and all these will be balanced against economic constraints, cultural predilections, individual patient preferences and the physician’s knowledge base. That knowledge base integrates medical foundations, honed by the wealth of the years of experience and the logic of every available evidence. It is in the latter where guidelines and recommendations are factored consideraby.

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