Review
Treatment of cardiac diseases: evidence based or experience based medicine?
W Kübler
Medizinische
Universitätsklinik (Ludolf-Krehl-Klinik), Bergheimer Strasse 58, 69115 Heidelberg, Germany
Correspondence to: Professor Kübler
Accepted 23 March 2000
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Owing
to the unexpected results of some studies, such as CAST (cardiac
arrhythmia suppression trial)1 and the World Health Organization clofibrate trial,2 or the studies with cAMP
dependent positive inotropic agents, the results of randomised
controlled trials are taken to represent the gold standard for
therapeutic decisions ("evidence based medicine"). The information
gain increases as one proceeds from anecdotal case reports over series
of observations, to case-control studies, cohort studies, small
randomised controlled trials and their meta-analyses (the results of
which are not confirmed by randomised controlled trials in up to
30%3), large randomised controlled trials, and finally to
careful meta-analyses of such trials (Cochrane criteria). Surrogate end
points based on the expectation of a beneficial effect may lead to
erroneous conclusions; the gold standard involves primary, hard end
points
predominantly prolongation of lifewhich may be quality adjusted.
However, even where the results of large randomised controlled trials
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