title: The Room Where It Happens: A Skeptic's Analysis of the New Heart Failure Guidelines.
abstract: New heart failure guidelines have been issued during the past several months, both in the United States and in Europe, in response to recent advances in and the approval of new drugs for the treatment of heart failure. Although guidelines documents are often viewed as authoritative and purely evidence-based, there are replete with meaningful (and inexplicable) inconsistencies, which derive from a review of the same body of scientific data by different groups. This satirical review highlights several examples of the entertaining foolishness of recent guideline documents in the good-natured hope that physicians will understand what the guidelines are, and more importantly, what they are not. Specifically, this paper describes the emergence of a new nonexistent disease; the strange battle between 2 bradycardic drugs (digoxin and ivabradine); the confusion that reigns over the positioning and dosing of inhibitors of the renin-angiotensin system; and the special recommendations that have been issued for certain special populations. As Otto von Bismarck remarked, guideline deliberations are like sausages; it is better not to see them being made. Yet, even after they are ready for public view, we should be cautious. Practitioners who rely on them for clinical decision-making engage in an unnecessary form of self-deception; those who read them literally and adhere to them strictly do not practice evidence-based medicine; and those who delve into them in a search for the truth are destined to be disappointed.
authors.affiliation: Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas. Electronic address: milton.packer@baylorhealth.edu.
authors.forename: Milton
authors.initials: M
authors.lastname: Packer
mesh_terms: D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D004232:Diuretics / Q000627:therapeutic use; D005060:Europe; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic / Q000592:standards*; D011379:Prognosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000187:drug effects; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000889:Anti-Arrhythmia Agents; D004232:Diuretics
keywords: Guidelines