With one out of three Americans killed by either heart attack or stroke, the vigorous competition between various committees and think tanks to a medically and politically viable solution was perhaps a natural reaction. Finally, it seemed, an august group of scientific minds had formed the nucleus of a group that would head up a move forward against the epidemic. The group had met for five years without being paid a dime to develop new criteria for guidelines that would prevent heart attacks and strokes in the general populace. The guidelines seemed to meet all medical muster; they also seemed to be politically viable as well. The guidelines were released on November 14, 2013. Barely a month passed before they were completely torn apart by expert scrutiny.
The annual meeting of the American Heart Association served as the backdrop for the dismembering of the new guidelines, with many leading cardiologists questioning not only the guidelines themselves but the methods by which committees come up with new protocol. Questions were raised about the evidence that is used to direct the practice of medicine, how large changes in public policy should be introduced into society and even the system by which medical precedent is to be included in future policy debates.
A recent past President of the American College of Cardiology, Cleveland doctor Dr. Steven Nissen, predicted an enormous backlash to the new guidelines. Medical professionals pointed to many reasons why the findings of the committee were not sound:
– The committee did not consider evidence outside of a very narrow band of randomized studies.
Although the randomized study usually provides the gold standard of medical evidence, critics of the think tank say that the evidence that was considered was simply too narrow. Many other examples of studies providing information that might have led to different conclusions by the committee was brought up at the AMA conference. These criticisms simply could not be scientifically refuted by the data that the committee had gathered in their time together.
– The committee was severely underfunded according to the precedent that had been set by previously successful think tanks and studies.
Many cardiologists pointed to the fact that the committee did not have the funds to consider a wider variety of evidence in their trials. Because of the monetary limitations in the studies, the findings could not stand up to the scrutiny of evidence beyond those few randomized trials that were considered by the committee. Some cardiologists likened the guidelines to trying to paint a 15 color mural with only two colors.
– The committee did not consider the political ramifications of large scale medical change.
Even critics who did not necessarily have a problem with the medical findings of the think tank took notable exception with the implementation of the findings of the committee. Most of the medical experts thought that the committee did not take into account the difficulties of actually incorporating the findings of an admittedly esoteric study into the day to day lives of the general public.
Some of the suggestions of the committee that received widespread disdain included the following.
One – Doctors were taken aback that they were being told to stop the monitoring of LDL cholesterol levels in their patients. The practice is decades old and has the backing of the wider medical community on the basis of countless studies which the think tank was unable to scientifically refute.
Two – Harvard professors found evidence that the online calculator that the committee backed actually overestimated the probability that a patient would have a heart attack or a stroke.
Three – Because of funding issues, the committee was only able to adequately study a total of three out of the 18 original questions that it had set out to answer. The National Institutes of Health, the funding party for the committee, was simply not willing to provide adequate funding for the entire effort as detailed by the original wishes of the committee.
Four – Reputable agencies such as the The National Lipid Association pulled out of their backing of the study or walked back their support of it before the guidelines were made public. Also, public comment was not provided for before the guidelines were released, raising the question of secrecy within the process.
One of the more agreeable solutions to the problem of funding as well as scrutiny included expanding the next effort into a worldwide study. Doing so, said Dr. Seth Martin at Johns Hopkins as well as many other experts, might provide more avenues for funding as well as the inclusion of many different standards of medical practice. Guidelines that could pass muster under the scrutiny of Spanish doctors as well as Finnish medical professionals (and American doctors and so on) have a much better chance of being correct as well as accepted, say many medical professionals.