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Gone are the days when guidelines could be ignored as cookbook medicine, the overweening influence of purchasers, or a simplistic view of the world with little value in practical patient management. Most would now accept the broad principle that it is a part of good clinical medicine to assess practice against standards linked explicitly to scientific evidence. In this issue Peters and Bredee1 discuss new guidelines from the Netherlands on coronary revascularisation and make a bold proposal for their use in practice. What sense are we to make of this among the plethora of guidelines and quality of care studies?
Guidelines: proliferation or unification?
Guidelines, scarce 10 years ago, now abound; most areas of suspected and proved coronary artery disease are now covered by one or more guideline. In the US, aspects of the invasive management of coronary disease are dealt with in procedure specific guidelines (on exercise electrocardiography, coronary angiography, angioplasty, stents, coronary artery bypass grafts) as well as guidelines for separate clinical presentations (chronic stable angina, unstable angina, acute myocardial infarction) issued by the American College of Cardiology/American Heart Association (www.acc.org/clinical/guidelines/index.html) or Agency for Health Care Policy and Research. It is possible therefore that the care of a single cardiac patient may come under the remit of half a dozen different guidelines from the same organisation. The European Society of Cardiology (www.escardio.org) has issued guidelines on the management of chronic stable angina and myocardial infarction, as has the British Cardiac Society (www.bcs.com). Neither organisation has published guidelines specifically …