Limited-resource, limited-guideline? Towards the delivery of appropriate and contextual cardiovascular care across settings

This commentary refers to ‘Applicability of European Society of Cardiology guidelines according to gross national income’, by W.B. van Dijk et al., https://doi.org/10.1093/eurheartj/ehac606 Societal guidelines are developed through a rigorous process involving multidisciplinary experts and evidence synthesis and drive clinical practice worldwide. Adoption of guidelines, however, can vary greatly due to resource constraints and other contextual factors. Van Dijk et al. finds that the implementation of European Society of Cardiology guidelines decreases as countries’ gross national income decreases.1 In other words, whereas high-income countries have a high implementation of guidelines, low- and middle-income countries (LMICs) do not. Barriers mainly include a lack of reimbursement of drugs and other care-related financial barriers. The authors are to be applauded for their important work, which underlines the poor generalizability of regional guidelines to other parts of the world. Cardiovascular guidelines have largely originated from major societies in North America and Europe. These guidelines have consistently been considered best practices for cardiovascular care and are, therefore, generally adopted worldwide. However, these guidelines have been developed with North American and European populations and health systems in mind, are informed by North American and European experts, and rely on evidence from trials and large observational studies that predominantly originate from high-income countries. Yet, differences exist in genetics, pathophysiology, and epidemiology across different regions. Similarly, systemic factors, such as health technology assessment, regulatory approval processes, and reimbursement mechanisms, vary and fragment the global generalizability of guidelines. Moreover, the costs and availability of drugs, equipment, and healthcare services differ widely worldwide. Cardiovascular and surgical supply chains are a considerable struggle in LMICs resulting in periodic stockouts of essential drugs and consumables.2 When available, costs may be prohibitive, either for patients and their families or for institutions themselves, limiting appropriate adoption of ‘global’ guidelines. Lastly, cultural, religious, and societal factors may influence the consideration of ‘appropriate use’ across different settings. It may be expected that the findings from the authors are similar, if not worse, for cardiac surgical guidelines. Six billion people lack access to safe, timely, and affordable cardiac surgical care when needed, whereby more than 100 countries and territories lack even a single cardiac surgeon.3 For example, for valvular surgery, the decision to replace or repair a valve is not always purely clinical4: the absence of valvular prostheses may force surgeons to repair a valve that may not be fully repairable. Similarly, the decision to use a mechanical or biological prosthesis is often an age-based and patient-driven one; the absence of one or another makes such decision-making and guideline recommendations obsolete. Collectively, these issues question whether existing guidelines should be considered the guiding light for cardiovascular care worldwide. The authors thoughtfully propose that ‘second and third best recommendations, for example, based on income levels’ may be included in future guidelines.1 Perhaps more appropriately and where possible, regional and/or national guidelines adapted to the local context, informed by representative stakeholders, and developed by the respective cardiology and cardiac surgical societies may be developed. Regardless, it is clear that change is urgently needed to deliver appropriate and contextual cardiovascular care in any setting: limited-resource settings should not equate to limited-guideline settings. D.V. is supported by the Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship. All authors declare no conflict of interest for this contribution.

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