Evaluation of natriuretic peptide recommendations in heart failure clinical practice guidelines☆
Graphical abstract
Introduction
Clinical practice guidelines (CPGs) are produced to facilitate incorporation of evidence into clinical practice. With a wider acceptance of natriuretic peptides (NPs) as an important part of the pathogenesis in heart failure (HF), they have been included in a number of clinical practice guidelines.
CPGs guidelines follow a methodology to: set questions; collect and evaluate the evidence they present; and rank the guidance offered. Systematic review (SR) of the available evidence is an important part of guideline development and is listed as a standard by the Institute of Medicine, which should be met by guideline writers [1]. SRs consider the body of available evidence with critical appraisal in way that minimizes bias and random error. Thus a well conducted SR is more likely to estimate the true effect of an intervention than individual studies. There is a role for recent well conducted individual studies to be considered in guideline development in an effort to reflect the most current literature. In a typical evidence hierarchy, SR of randomized controlled trial (RCT) data would be seen as a higher level of evidence than individual RCTs, and SR of non-randomized studies considered a higher level of evidence than the individual non-randomized studies. RCT for evaluation of diagnostic laboratory tests are not common and thus the evidence is often based on non-randomized studies [2]. The Centre for Evidence Based Medicine (CEBM) has a table describing the different types of evidence available and how these could be ranked for different purposes including diagnosis and prognosis [3].
The Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) is widely used appraisal tool for guidelines, and has been validated for use in both clinical and laboratory medicine guidelines [4], [5]. Guidelines in cardiology have been criticized for not meeting the AGREE II criteria [6]. Methodological quality was noted to be one of the weaker aspects of guidelines in cardiology. Consideration of the best available body of evidence is an important component of methodological rigor. For medical tests included in CPGs a list of important factors for consideration has been proposed [7]. This list has been used to evaluate a number of CPGs but has not yet been adopted on a wide basis.
A number of systematic reviews have considered NPs in the setting of their research question in HF [8]. The systematic reviews have demonstrated that NPs have clinical utility, particularly in excluding HF, as NPs have excellent negative predictive value for HF. Given that there is a strong body of evidence for NPs in HF evaluated by SR, the recommended use of NPs should be consistent between different guidelines asking the same question and should be consistent with the SR literature on the topic.
This study investigates the question of whether the current HF CPGs use the highest available level of evidence to support the recommendations for NP use. To answer this question, this study critically evaluates the recommendations for use of NPs reported in HF CPGs. This was achieved by identifying CPG recommendations, evaluating the quality of the CPGs, identifying the evidence supporting CPG recommendations for NPs and evaluating the reporting of laboratory factors related to the recommendations.
Section snippets
Clinical practice guideline
A search for clinical practice guidelines for heart failure was undertaken using PubMed, EMBASE, Medline, Cochrane database, the National Institute for Clinical Excellence website, the Scottish Intercollegiate Guideline Network and the Guideline Clearing House in Jan 2015. Search terms used were ‘guidelines’ and ‘heart failure’. Guidelines published since 2011 were included. Guideline documents that were not supported by a specialty society were excluded. Guidelines that commented on the
Clinical practice guidelines for heart failure
Seven CPGs were included once duplicates, guidelines published prior to 2011 and guidelines that met exclusion criteria [11], [12], [13] were excluded. The included CPGs were published by the Canadian Cardiovascular Society (CCS) [14], the American College of Cardiology/American Heart Association (AHA) [15], the European Society of Cardiology (ESC) [16], the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (ANZ) [17], National Institute for Health and Care
Highest level of evidence
The most interesting finding in this study is the lack of consideration for published SR by the CPG writers. The use of SR is one of the standards in the Institute of Medicine (IOM) document and thus the HF CPGs do not adequately meet this standard [1]. One CPG conducted a SR and is the only CPG to meet the IOM SR standard. The CPG writers for the HF guidelines have most often cited individual studies to support their recommendations (Fig. 1). All evidence hierarchies place SR at a higher level
Summary of recommendations for improving clinical practice guidelines
Firstly the organizations producing CPG's should review their methodology and make this compliant with the IOM recommendations and take into consideration the elements of the AGREE tool [1], [4]. Secondly, the people selected to participate in CPG development should be given the opportunity to review the IOM recommendations, the AGREE tool and the organizational methodology for producing a CPG. Potentially training could be offered for CPG committee members. Finally, CPGs should be sent to
Conclusion
This report documents the current (2011–2014) CPG for HF recommendations for the use of NPs and the evidence used to support the recommendations. A gap between the IOM standard for evidence evaluation and the evidence evaluation recommended by cardiology societies has been identified. The CPG recommendations are partially supported by SR findings. The type of evidence considered by future CPGs should consider SR that have already been published in their review of evidence or commission SR to
Acknowledgments
P. Lina Santaguida for helpful suggestions during the preparation of the manuscript.
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