Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction.

Background: Implantable cardioverter-defibrillator (ICD) therapy has been shown to improve survival in patients with various heart conditions who are at high risk for ventricular arrhythmias. Whether benefit occurs in patients early after myocardial infarction is unknown.

Methods: We conducted the Defibrillator in Acute Myocardial Infarction Trial, a randomized, open-label comparison of ICD therapy (in 332 patients) and no ICD therapy (in 342 patients) 6 to 40 days after a myocardial infarction.

Guidelines--for the obedience of fools and the guidance of wise men?

Guidelines for medical management are now part of medical life. A fool--loosely defined as someone who does not know much about a particular area of medicine--will do well to follow guidelines when treating patients, but a wise man (again, loosely defined as someone who does know about the disease in question) might do better not to follow them slavishly. The problem is that the evidence on which guidelines are based is seldom very good.

Difficulties of introducing the National Service Framework for heart failure into general practice in the UK.

Background: The National Service Framework (NSF) sets standards for the management of heart failure in the UK. Loop diuretics are commonly first prescribed in primary care. Some patients taking these drugs have heart failure and may benefit from other treatments including ACE inhibitors.

The diagnosis of heart failure in general practice: implications for the UK National Service Framework.

Background: The UK National Service Framework recommends patients with suspected heart failure undergo echocardiography. Selection of patients for this investigation in primary care is difficult. It is not clear which clinical features best identify patients with left ventricular systolic dysfunction.

Evidence-based medicine, opinion-based medicine, and real-world medicine.

The freedom of a doctor to treat an individual patient in the way he believes best has been markedly limited by the concept of evidence-based medicine. Clearly all would wish to practice according to the best available evidence, but it has become accepted that "evidence-based" means that which is derived from randomized, and preferably double-blind, clinical trials. The history of clinical trial development, which can be traced to the use of oranges and lemons for the treatment of scurvy in 1747, has reflected a progressive need to establish whether smaller and smaller effects of treatment are real.

Assessing exercise capacity, quality of life and haemodynamics in heart failure: do the tests tell us the same thing?

Background: The objective measurement of exercise tolerance is an important component of heart failure trials. The use of laboratory-based treadmill exercise testing has attracted criticism, however, as being unrepresentative of patients' true capabilities.

Aim: To examine the relationships between tests of exercise capacity, quality of life and haemodynamics in patients with stable symptomatic heart failure.