In the end it wasn't wisdom for the ages. The American College of Cardiology said today that it was withdrawing one of its five recommendations in the "Choosing Wisely" campaign. In 2012 the ACC recommended that heart attack patients should have only their culprit artery unblocked. It said that patients and caregivers should question whether complete revascularization of all nonculprit lesions in heart attack patients should be performed.
The original recommendation was based on non-randomized studies suggesting that treating all significantly blocked vessels in heart attack patients could be harmful. "However," the ACC now states, "over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization."
Two recent randomized controlled trials have altered the field. The 2013 PRAMI trial and last month's CvLPRIT trial offered evidence that stenting all arteries with large blockages improved the outcome of heart attack patients. But the studies, the ACC states, left many open questions "about the exact timing of the procedures; whether certain patients benefit versus others; whether FFR might guide decisions; and the role of patient complexity and hemodynamic stability."
“Science is not static but rather constantly evolving,” said ACC President Patrick T. O’Gara, in a press release. He said current clinical guidelines and appropriate use criteria recommendations will also address the impact of the trials. The ACC said it plans to update its "Choosing Wisely" recommendations.
Asked to comment, cardiologist Sanjay Kaul said that "Choosing Wisely should be based on strong evidence of harm or no benefit. Evidence derived from nonrandomized trials (or their pooled analyses) hardly qualifies to justify putting things on Choosing Wisely list!" On the other hand, he said that he "would also argue that one requires strong evidence to 'undo' (modify) recommendations. While evidence from PRAMI and unpublished evidence from CvLPRIT is stronger than nonrandomized studies, they still don't answer the clinically important question."
In other words, to summarize Kaul, it was a mistake to make the recommendation in the first place but it may be an equal and perhaps even greater mistake to remove the recommendation now based on the new but still insufficient evidence.
In my opinion, Choosing Wisely is a great idea and it has done far more good than bad. But public recommendations like these, along with medical guidelines, have the potential for causing great harm. As I wrote recently about guidelines, "we need fewer and shorter guidelines. In fact, I'd like to propose that guidelines, like war, should be waged only when there is absolute consensus and overwhelming evidence."
It seems to me that the medical organizations that produce guidelines should freely admit this lack of evidence for most recommendations. Then, instead of getting their panties all in a bunch trying to defend the indefensible-- as we saw recently with the salt guideline-- they could advocate for better evidence. After all, it's hard to convince anyone that more trials and data are necessary when there's already a hundred pages of densely-referenced guidelines on the topic, and the assemblage of learned experts all express unanimous agreement about the best course of treatment. Who needs data in that case?
So if they want to make the case for more data they will have to first acknowledge their ignorance. And that will first require that rather than browbeat their committees into unanimity, they agree to disagree and express a variety of opinions.
