Transcript British Guideline on the Management of Asthma

SIGN Heart Disease
Guidelines
Five national clinical guidelines
www.sign.ac.uk
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Key points - prevention
• everyone over 40 years old in Scotland should be assessed for risk of
CHD (and stroke) at least every five years.
• more people should be considered for statin drugs to reduce
cholesterol levels before they have an event (including people with a
risk of CHD or stroke of 20 per cent or more over 10 years, rather than
the previous recommendation of 30 percent or more for CHD alone), as
well as low-dose aspirin which reduces the risk of blood clots.
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Key points – treatment (1)
• patients with the most serious type of heart attack (ST elevation acute
coronary syndrome) should be admitted to a regional cardiac
intervention laboratory to remove the causal blood clot and narrowed
artery (angioplasty) and implant a stent to keep the artery open. If this
is not possible within 90 minutes of diagnosis, they should rapidly
receive the most effective clot-busting drugs (thrombolytics).
• high risk patients with non-ST elevation acute coronary syndrome
should receive early angiography and be evaluated for possible
angioplasty and stenting.
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Key points – treatment (2)
• more patients with arrhythmias and heart failure should receive
implantable cardiac defibrillators (ICDs) and cardiac resynchronisation
therapy (CRT), to reduce the risk of sudden death.
• discharge arrangements for patients hospitalised with heart failure
should be improved, to augment the existing primary care services.
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The 5 CHD guidelines
• SIGN 93 - Acute coronary syndromes
• SIGN 94 - Cardiac arrhythmias in coronary heart
disease
• SIGN 95 - Management of chronic heart failure
• SIGN 96 - Management of stable angina
• SIGN 97 - Risk estimation and the prevention of
cardiovascular disease
• National clinical and resource impact assessment
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Development of the guideline
• Involved 105 NHS and voluntary sector staff and patients and
carer representatives from all over Scotland
• Uses SIGN evidence-based methodology
• Initial literature searches based on 130 key questions
identified130,000 research papers
• 3,000 relevant published papers up to the end of 2005 were
reviewed
• 5 multidisciplinary groups reviewed the evidence
• Formal review by 131 peer reviewers
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Levels of evidence
1++ High quality meta-analyses, systematic reviews, or randomised
controlled trials (RCTs) with a very low risk of bias
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1+
Well-conducted meta-analyses, systematic reviews, or RCTs with a low
risk of bias
1
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
Levels of evidence
1++ High quality meta-analyses, systematic reviews, or randomised
controlled trials (RCTs) with a very low risk of bias
1+
Well-conducted meta-analyses, systematic reviews, or RCTs with a low
risk of bias
1
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is causal
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2+
Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2
Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
Levels of evidence
1++ High quality meta-analyses, systematic reviews, or RCTs with a very
low risk of bias
1+
Well-conducted meta-analyses, systematic reviews, or RCTs with a low
risk of bias
1
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is causal
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2+
Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2
Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
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Non-analytic studies, e.g. case reports, case series
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Expert opinion
Grades of recommendation
• Relate to strength of evidence, not clinical importance
• Low grade recommendations in important clinical areas should stimulate
research
Recommendation Evidence
A
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At least one 1++ directly applicable to target population; or
Many studies 1+ directly applicable to target population and
demonstrating consistency
Grades of recommendation
Recommendation Evidence
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A
At least one 1++ directly applicable to target population; or
Many studies 1+ directly applicable to target population and
demonstrating consistency
B
Many 2++ directly applicable to target population and
demonstrating consistency; or
Extrapolated evidence from studies rated as 1++ or 1+
Grades of recommendation
Recommendation Evidence
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A
At least one 1++ directly applicable to target population; or
Many studies 1+ directly applicable to target population and
demonstrating consistency
B
Many 2++ directly applicable to target population and
demonstrating consistency; or
Extrapolated evidence from studies rated as 1++ or 1+
C
Many 2+ directly applicable to target population and
demonstrating consistency; or
Extrapolated evidence from studies rated as 2++
Grades of recommendation
Recommendation Evidence
A
At least one 1++ directly applicable to target population; or
Many studies 1+ directly applicable to target population and
demonstrating consistency
B
Many 2++ directly applicable to target population and
demonstrating consistency; or
Extrapolated evidence from studies rated as 1++ or 1+
C
Many 2+ directly applicable to target population and demonstrating
consistency; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Remember – grades relate to strength of evidence, not clinical importance
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Grades of recommendation
Recommendation Evidence
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A
At least one 1++ directly applicable to target population; or
Many studies 1+ directly applicable to target population and
demonstrating consistency
B
Many 2++ directly applicable to target population and
demonstrating consistency; or
Extrapolated evidence from studies rated as 1++ or 1+
C
Many 2+ directly applicable to target population and demonstrating
consistency; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+

Good practice points
Recommended best practice based on the clinical experience
of the guideline development group
Summary
The SIGN CHD guidelines are based on evidence and
were developed using a recognised methodology
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