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The Beta Blocker and Clonidine Protocol

Lesson 6
ACC & AHA Guidelines

8. Guideline chaos: conflicting recommendations for preoperative cardiac assessment
(Am J Cardiol. 2003 Jun 1;91(11):1299-303)

bullet The American College of Cardiology/American Heart Association (ACC/AHA)
bullet The American College of Physicians (ACP)
bullet Disseminated guidelines to assess preoperative cardiac risks before noncardiac surgery
bullet Do guidelines differ in preoperative recommendations for a group of patients? Do they differ from actual provider recommendations?
bullet Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1, 1998
bullet Recommendations for preoperative testing were discordant between guidelines for 17% of patients (kappa = 0.38).
bullet Guidelines never agreed on the need for noninvasive stress testing.
bullet Extreme differences in recommendations (7%).
bullet Physicians ordered NST more often (n = 27) than either guideline
bullet When applied to real patients being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in recommendations for preoperative cardiac testing.

Can doctors in the real world follow the AHA/ACC guidelines? NO. In a study of this exact question Doctors at a Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1, 1998 tried to follow the AHA/ACC guidelines and ended up with Guideline chaos: conflicting recommendations for preoperative cardiac assessment (Am J Cardiol. 2003 Jun 1;91(11):1299-303). Guidelines never agreed on the need for noninvasive stress testing. There were extreme differences in recommendations (7%). Even when physicians really tried to follow the recommendations, they ordered non invasive stress testing more often (n = 27) than either guideline. When applied to real patients being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in recommendations for preoperative cardiac testing.

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