Giner-Galvañ Vicente, Esteban-Giner María José, Pallarés-Carratalá Vicente
Department of General Internal Medicine, Unit of Hypertension and Cardiometabolic Risk, Hospital Mare de Déu dels Lliris, Alcoy, Alicante.
Department of Health Surveillance, Unión de Mutuas, Castellón de la Plana; Department of Medicine, Universitat Jaume I, Castellón, Spain.
Vasc Health Risk Manag. 2016 Sep 6;12:357-369. doi: 10.2147/VHRM.S89038. eCollection 2016.
Modern medicine is characterized by a continuous genesis of evidence making it very difficult to translate the latest findings into a better clinical practice. Clinical practice guidelines (CPG) emerge to provide clinicians evidence-based recommendations for their daily clinical practice. However, the high number of existing CPG as well as the usual differences in the given recommendations usually increases the clinician's confusion and doubts. It has apparently been the case for the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol. These CPG proposed new and controversial concepts that have usually been considered an antagonist shift respective to European CPG. The most controversial published proposals are: 1) to consider evidence just from randomized clinical trials, 2) creation of a new cardiovascular (CV) risk calculator, 3) to consider reducing CV risk instead of reducing low-density lipoprotein cholesterol (LDLc) as the target of the treatment, and 4) consideration of statins as the only drugs for treatment. A deep analysis of the 2013 American College of Cardiology/American Heart Association CPG and comparison with the European ones show that from a practical and clinical point of view, there are more similarities than differences. To further help clinicians in their daily work, in the present globalized world, it is time to discuss and adopt a mutually agreed upon document created by both sides of the Atlantic. Probably it is not a short-term solution. Meanwhile, taking advantage of the similarities, the recommended practical attitude for the daily clinical practice should be based on 1) early detection of people with increased CV risk promoting the use of validated local scales, 2) reinforce the mainstream importance of nonpharmacological treatment, and 3) need for periodically monitoring response with analytical parameters (LDL or non-high-density lipoprotein cholesterol) and global CV risk estimation. Technological solutions such as the big data technology could help to obtain high-quality evidence in an intermediate term.
现代医学的特点是证据不断涌现，这使得将最新研究成果转化为更好的临床实践变得极为困难。临床实践指南（CPG）应运而生，为临床医生的日常临床实践提供基于证据的建议。然而，现有CPG数量众多，且所给出的建议通常存在差异，这往往增加了临床医生的困惑与疑虑。2013年美国心脏病学会/美国心脏协会（ACC/AHA）血液胆固醇治疗指南显然就是这种情况。这些CPG提出了新的且具争议性的概念，相对于欧洲CPG而言，这些概念通常被视为一种对立的转变。最具争议的已发表提议包括：1）仅考虑来自随机临床试验的证据；2）创建一种新的心血管（CV）风险计算器；3）将降低CV风险而非降低低密度脂蛋白胆固醇（LDLc）视为治疗目标；4）将他汀类药物视为唯一的治疗药物。对2013年美国心脏病学会/美国心脏协会CPG进行深入分析，并与欧洲的CPG进行比较后发现，从实践和临床角度来看，两者的相似之处多于差异。为了在日常工作中进一步帮助临床医生，在当今全球化的世界中，是时候讨论并采用一份由大西洋两岸共同商定的文件了。这可能不是一个短期解决方案。与此同时，利用这些相似之处，日常临床实践中推荐的实际态度应基于：1）早期发现CV风险增加的人群，推广使用经过验证的本地量表；2）强化非药物治疗的主流重要性；3）需要定期通过分析参数（LDL或非高密度脂蛋白胆固醇）监测反应，并进行整体CV风险评估。大数据技术等技术解决方案有助于在中期获得高质量证据。
