Interpreting Scripture

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In the current issue of Clinical Cardiology, Nanette Wenger, Professor Emeritus of Cardiology at Emory University and regular fixture on the AHA and ACC guideline-writing committees, offers us a “guide to the guidelines” article that summarizes the pertinent recommendations in the 2011 Update to the AHA Guidelines for Prevention of Cardiovascular Disease in Women.

Now it may puzzle the lay person that a guideline would need its own guide, but anyone who has seriously attempted to read the master document in the original language will clearly concede that the risk of narcoleptic seizure is not insignificant.  Hence, the possibility that the message contained therein may not be fully appreciated by the masses of discombobulated physicians, and the urgent need to re-emphasize once again, and in the style of Mr. Perry, that when it comes to cardiovascular disease, women are now the same as men, except that before we knew that, we thought they were different, but now that we know the evidence that before we didn’t know, we need more research to know better what we didn’t know before we knew we didn’t know, because it may not be completely the same…

A noteworthy departure from the usual practice, is the decision by our wise experts to favor “effectiveness-based” recommendations over “evidence-based” ones with curious definitions for each standard:

A major evolution from previous guidelines to the 2011 update is that effectiveness (benefits and risks observed in clinical practice) of preventive therapies was strongly considered and recommendations were not limited to evidence that documents efficacy (benefits observed in clinical research).

One is left to wonder 1) how observations in clinical practice can be made without clinical research 2) who is to do the observing, and 3) what criteria of effectiveness are we talking about, but again, we should be familiar by now with outcomes research newspeak

Wenger serves us with a particularly amusing rendition:

At least 1 major risk factor is used to define the population of “at risk” women.  These risk factors include cigarette smoking, hypertension, dyslipidemia, obesity, poor diet(…) Important added characteristics include evidence of subclinical atherosclerosis such as coronary calcification, carotid plaque, or intima-media thickening (…)

to conclude:

Women with these “at risk disorders” should be screened for cardiovascular risk factors.


Of course, one of the main points of the guidelines is to reiterate (if anyone had any lingering doubt!) that everybody is “at risk” and deserving of evaluation and “management,”  even though age-adjusted mortality has been declining since the 1960’s and plunging in recent years.  This means that we are mainly talking about preventing cardiac disease in octogenerians and therefore, according Paul Dudley White, trying to prevent “an act of God.”

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