Acute coronary syndromes: consensus recommendations for translating knowledge into action

To the Editor: The recent discussion in the Journal on acute coronary syndromes is welcome. Forge1 questions the validity of the National Heart Foundation of Australia (NHFA) guidelines,2 which recommend universal routine early invasive management for patients with high-risk non-ST-elevation myocardial infarction (NSTEMI), interpreted by Forge as “virtually all patients with objective evidence of ischaemia”.

As older patients usually have comorbidities, often major, the influence of NSTEMI on the clinical picture can be uncertain. Transfer from local surroundings and family support is a major decision. It is critical to establish which subgroups gain from early percutaneous coronary intervention, at present not clearly defined. The number needed to treat for substantial benefit is an essential guide to management policy.

The logistics of transfer are complex, involving time and distance factors, availability of ambulances and cardiology beds — after acceptance by patient and relatives. Forge validly emphasises the potential loss of intensive cardiac care skills, staff morale and recruitment from the early transfer policy and large costs to the country hospitals from ambulance fees.

It is irrefutable that general implementation of the NHFA guidelines would be a major budget item, involving specialised laboratory facilities with nursing, resident and interventional cardiologist availability, 24 hours a day, 7 days a week. Potentially, there are many competing medical financial needs, which a better targeted coronary intervention program could facilitate.

Forge raises the issue of conflict of interest in relation to the development of the guidelines. Breiger and colleagues read this as an accusation that they had a pecuniary interest as authors.3 Their stated competing interests list membership of advisory boards, payment for presentations and expert testimony, receipt of research grants, and travel and accommodation expenses. This reflects their role as medical advisors to pharmaceutical and biotechnology companies.

What is the aim of publishing competing interests except to provide a guide to significant potential bias affecting the validity of the presentation? Does the editorial staff have criteria for rejection of submissions for publication, or are readers left to make their own judgements?

It is undoubted that a major expansion in expensive medical procedures would increase cardiologists’ income, but this is only one component of the program budget. The broader issue is that conflict of interest remains an integral part of personal and professional life, not easily controllable by governance.