Heart Failure Guidelines are Evidence-Based, but are They Patient-Centered?

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Introduction To apply evidence-based medicine (EBM) to individual patients and implement shared decision-making, it is necessary for clinical practice guidelines (CPGs) to incorporate performance metrics for diagnostic studies and therapeutic interventions, as well as relevant patient contexts. This is especially important in heart failure (HF), which is a highly heterogeneous population with a high prevalence of multimorbidity, and impairments in other domains (e.g. function and cognition) that can significantly impact the value of diagnostic studies and therapeutic interventions. We sought to determine the extent to which performance metrics and patient context are incorporated into major HF CPGs. Methods We reviewed the main and supplementary documents of 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) CPG, 2017 ACCF/AHA/HFSA update, and 2016 European Society of Cardiology (ESC) CPG. We assessed the following domains from each recommendation: performance metrics including sensitivity/specificity, positive/negative predictive value, number needed to treat, absolute benefit/harm, and time horizon to benefit; and patient context, including comorbidity, socio-personal milieu, personal preferences, and life expectancy. Results We examined 169 recommendations from the 2013 ACCF/AHA CPG and 2017 update, and 187 recommendations from the 2016 ESC CPG. Performance metrics for diagnostic studies were rarely included; metrics for therapeutic interventions were included to a varying degree depending on the CPG (Figure). Sensitivity/specificity, time horizon to benefit, and absolute benefits were mentioned in 7%, 13%, and 30% of all recommendations, respectively. Patient context was included in over 60% of ACCF/AHA/HFSA CPG recommendations but only included in 25% of the ESC CPG recommendations (Figure). Conclusion The majority of recommendations from HF CPGs lack granular information on diagnostic and therapeutic performance metrics. Contextual patient factors are also inconsistently included. These findings indicate that while HF CPGs may be evidence-based, they are not yet patient-centered. Given their importance to effectively implement EBM and shared decision-making among the complex and heterogeneous HF population, future CPGs should explicitly incorporate these aspects.