SIGN Heart Disease Guidelines Five national clinical guidelines sign.ac.uk

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SIGN Heart Disease Guidelines

Five national clinical guidelinesFive national clinical guidelines

www.sign.ac.uk

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• 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.

Key points - preventionKey points - prevention

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• 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.

Key points – treatment (1)Key points – treatment (1)

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• 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.

Key points – treatment (2)Key points – treatment (2)

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The 5 CHD guidelinesThe 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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• 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

Development of the guidelineDevelopment of the guideline

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Levels of evidenceLevels of evidence

11++++ High quality meta-analyses, systematic reviews, or randomised High quality meta-analyses, systematic reviews, or randomised controlled trials (RCTs) with a very low risk of biascontrolled trials (RCTs) with a very low risk of bias

11++ Well-conducted meta-analyses, systematic reviews, or RCTs with a low Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of biasrisk of bias

11 Meta-analyses, systematic reviews, or RCTs with a high risk of biasMeta-analyses, systematic reviews, or RCTs with a high risk of bias

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Levels of evidenceLevels of evidence1++ 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

22++++ High quality systematic reviews of case control or cohort studiesHigh quality systematic reviews of case control or cohort studiesHigh quality case control or cohort studies with a very low risk of High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalconfounding or bias and a high probability that the relationship is causal

22++ Well-conducted case control or cohort studies with a low risk of Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is confounding or bias and a moderate probability that the relationship is causalcausal

22 Case control or cohort studies with a high risk of confounding or bias Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causaland a significant risk that the relationship is not causal

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Levels of evidenceLevels of evidence1++ 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 studiesHigh quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

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

33 Non-analytic studies, e.g. case reports, case seriesNon-analytic studies, e.g. case reports, case series

44 Expert opinionExpert opinion

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Grades of recommendationGrades of recommendation

• Relate to strength of evidence, not clinical importance

• Low grade recommendations in important clinical areas should stimulate research

RecommendationRecommendation EvidenceEvidence

AAAt least one 1At least one 1++++ directly applicable to target population directly applicable to target population; or; orMany studies 1Many studies 1++ directly applicable to target population and directly applicable to target population and demonstrating consistencydemonstrating consistency

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AAt least one 1++ directly applicable to target population; orMany studies 1+ directly applicable to target population and demonstrating consistency

BBMany 2Many 2++++ directly applicable to target population and directly applicable to target population and demonstrating consistencydemonstrating consistency; or; orExtrapolated evidence from studies rated as 1Extrapolated evidence from studies rated as 1++++ or 1 or 1++

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BMany 2++ directly applicable to target population and demonstrating consistency; orExtrapolated evidence from studies rated as 1++ or 1+

CCMany 2Many 2++ directly applicable to target population and directly applicable to target population and demonstrating consistencydemonstrating consistency; or; orExtrapolated evidence from studies rated as 2Extrapolated evidence from studies rated as 2++++

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CMany 2+ directly applicable to target population and demonstrating consistency; orExtrapolated evidence from studies rated as 2++

DDEvidence level 3 or 4Evidence level 3 or 4; or; orExtrapolated evidence from studies rated as 2Extrapolated evidence from studies rated as 2++

Remember – grades relate to strength of evidence, not clinical importance

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CMany 2+ directly applicable to target population and demonstrating consistency; orExtrapolated evidence from studies rated as 2++

DEvidence level 3 or 4; orExtrapolated evidence from studies rated as 2+

Good practice points Good practice points Recommended best practice based on the clinical experience Recommended best practice based on the clinical experience of the guideline development groupof the guideline development group

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The SIGN CHD guidelines are based on evidence and

were developed using a recognised methodology

SummarySummary

Documents

SIGN Heart Disease Guidelines Five national clinical guidelines sign.ac.uk