ACC/AHA Guidelines: Not a Replacement for Clinical Contemplation

On May 19th the Journal of the American College of Cardiology published an illuminating paper by Pant et al. examining the impact of a dramatic change in one of the Cardiac Guidelines. The paper was entitled “Trends in Infective Endocarditis Incidence, Microbiology, and Valve Replacement in the United States from 2000 to 2011”. In 2007 the ACC/AHA Guidelines were radically shifted, advocating an enormous reduction in sub-acute bacterial endocarditis prophylaxis (SBEP) precautions. The rationale for the dramatic shift from an aggressive to a conservative stance emanated from two findings: a lack of RCT evidence for the need for SBEP precautions under most circumstances, and the growing problem of antibiotic resistance. Without claiming prescience or any other such miraculous gift, I will tell you that at the time I predicted a significant future rise in endocarditis. My belief was that the guidelines overshot their intentions. Some individuals, I surmised, have valvular heart disease that predisposes them to developing SBE yet fails to be “significant” enough to make them candidates for the revised SBEP recommendations.

For several years I bucked the system and continued my aggressive prophylaxis. Then I buckled. I followed the guidelines to a tee. Though none of my patients has developed SBE, I now question my decision to cave under the pressure of the guidelines. I have always been one to try to think through issues, to treat patients outside any preordained box and beyond an overly simplified algorithmic construct. But in this case I felt perhaps I should just go with the flow. In truth, it was just easier to do so. My liability was lessened and my decision-making efforts were simplified. Yet, in retrospect, seeing the predictable rise in streptococcal SBE, I have been forced to re-examine my decision. In doing so, once again I am confronted with our current fixation on RCTs as proof positive “evidence,” with all other levels of understanding being “non-evidence”.

The absence of RCTs in this construct is tantamount to a lack of evidence. This paradigm is of course false. Many levels of valid evidence exist and oversimplification, though appealing, is inherently flawed and theoretically dangerous. We see this now in eight years of follow up after the change in ACC/AHA SBEP Guidelines. We also see this in many other aspects of everyday practice. Though I chose an easier and perhaps idler path in this circumstance, I will now reverse my position and once again give greater thought to each SBEP recommendation I render. It will take longer to do so; more complex doctor-patient discussions will be required; and larger liability will fall upon my shoulders. But these are the elements required to be a better physician. I owe it to my patients, and equally importantly to myself, to do so. Having said this, pragmatic issues remain. How do we practice medicine in an efficient, cost-effective, economically sound, intellectually stimulating, personalized, high-level fashion, while adhering to the mounting pressure of regulatory changes and requirements? This is the question that requires our most focused attention yet typically receives short shrift. For modern American Medicine to enjoy the future we all believe it deserves, this question, along with its counterparts, deserves our full and undivided attention.

Learn more about preventive cardiology at

For more information about the supplements and vitamins critical to your everyday health visit

Comments { 0 }

The Emory Symposium on Coronary Atherosclerosis Prevention & Education

Here’s a shoutout to my friend and colleague, Dr. Larry Sperling.

The renowned Emory Heart Center of the Emory University School of Medicine will be holding its 13th annual Emory Symposium on Coronary Atherosclerosis Prevention & Education June 4-8, 2014. This year’s event, which is titled “Emory Escape 2014“, will be held at the OMNI Amelia Plantation on lovely Amelia Island, Florida..

The challenge
Cardiovascular disease remains the number one cause of death of men and women in the United States, and is a major cause of disability. The American Heart Association has a stated goal to reduce deaths from cardiovascular disease and stroke by 20% by 2020. In order to achieve this goal, physicians and clinicians must gain the knowledge, skill and resources to integrate the latest research and clinical guidelines in the context of their own practice.

The event
At ESCAPE attendees will hear nationally renowned speakers discuss the recently released, 2013 ACC/AHA guidelines on hypertension, blood cholesterol, obesity, healthy living and risk assessment. In addition, there will be one day dedicated to lectures on CV prevention in “special population” patients, including patients with HIV, PCOS, breast cancer, connective tissue disease and post renal transplant. There will also be lectures on electrophysiology, interventional cardiology, heart failure, tobacco cessation, and women’s heart health. This conference will close the knowledge gaps between national guideline goals, practice, and research. Physicians and clinicians will have the opportunity to discuss with the speakers and other attendees how these principles can be applied to patient care in the context of their own practice in order to decrease cardiovascular disease risk.

In addition to the extensive educational curriculum, events will include pre-meeting workshops,  an attendee and spouse session and a family social and cookout.

Who should attend
Cardiologists, internists, family practitioners, emergency medical personnel, primary care physicians and nurses can all benefit from this conference.

Register online at – registration deadline May 4th

Call 1-800-THE-OMNI to make room reservations.

Hosted by: Emory University School of Medicine Department of Medicine Division of Cardiology.

Learn more about preventive cardiology at

Learn more about essential vitamins and supplements at

Comments { 0 }

The Inclusiveness of Modern Medicine

Western Medicine has been branded non-inclusive, even close-minded. In many respects it deserves this designation. After all, medical guidelines have been constructed on dogma derived almost solely from “outcome trials”. Such trials are uniformly difficult to perform and have inherent constraints such as limited applicability to the specific patients we all see every day in practice. At times doctors do rely too heavily on guidelines and by so doing limit their own ability to think outside the box. Interestingly, doctors often utilize techniques and procedures in an “off label” fashion, meaning they are being used in ways for which they have not been approved, but they do so to benefit their patients. Still, most doctors fail to acknowledge the pervasiveness of “off label” practices and this self-blinding permits frequent condemnation of alternative or complementary strategies. For example, for years doctors have condemned chelation as pure quackery. Recently (TACT), a large clinical trial presented at both the American Heart Association (AHA) and American College of Cardiology (ACC) meetings, showed clinical benefit of this purportedly charlatan-based procedure. Another recent study noted that osteopathic maneuvers (also deemed useless by many western-minded physicians) appear to have real value. The long-awaited revised cholesterol guidelines are still in the process of being approved (this has been going on for many years). The hold-up – difficulty in creating guidelines based solely on high-level evidence. Translation; we recognize that we simply don’t know as much as we think, and sometimes pretend, to know.

So why, you may ask, is my title so optimistic? It’s because the winds of change are upon us. The subtle acceptance of methods such as chelation and osteopathy along with our guideline-related struggle to come to terms with our lack of knowledge speak volumes. We are coming to the point I believe, when we will be able to accept our imperfection. We will acknowledge the unique and permanent blend of art and science that is medicine. We will embrace our science-based creativity. By doing all this, we will enter a new, better, and more inclusive stage in the evolution of modern medicine.

Visit for more preventive healthcare solutions.

Comments { 2 }