There is a 17-year Gap Between New Knowledge and Practice: In Cardiovascular Disease it is 34 Years.
The National Academy of Medicine (previously the Institute of Medicine) has said there is a 17-year gap between new knowledge and practice in medicine. “It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven.” In cardiovascular and related conditions, the gap is twice as large.
Circulation is one of the most prestigious medical journals in cardiology. In 1988, there were two studies done that proved a heart artery stent cannot protect a patient with stable coronary artery disease from having a heart attack or falling to sudden cardiac death. This one from the Wake Forest School of Medicine was published in 1988. That is 34 years ago-twice the gap noted by the National Academy.
Heart artery catheterizations were done in 42 patients both before and up to a month after having a heart attack. Sixty-six precent of these patients had less than a 50% blockage in the involved artery before the heart attack occured because a cholesterol deposity ruptured causing a clot that blocked an artery. The blockage prior to the heart attack was less than 70% in 97% of the arteries involved in the heart attack that followed. There was no correlation between the severity of the initial heart artery blockage and the time from the first catheterization until the heart attack.
The authors concluded: “Because it was difficult to predict the site of the subsequent occlusion in our patients from the initial coronary angiogram , coronary bypass surgery or angioplasty appropriately directed only at the angio-graphically significant lesions initially present in almost all our patients would not have been effective in preventing the majority of myocardial infarctions. This does not indicate that arteries that do not have obstructive lesions should be bypassed or dilated. Instead, effective therapy to prevent myo-cardial infarction may need to be directed at the entire coronary tree, not just at obstructive lesions. Such therapy to prevent myocardial infarctions might rationally include avoiding smoking, reducing serum cholesterol, administering agents that alter platelet function such as aspirin or, possibly, fish oil, and pharmacological agents to prevent spasm of the coronary arteries.” These authors were making a pitch for optimal medical therapy 34 years ago and it is not widely available yet.
A subsequent article in Circulation in 1995 summarized the results of 3 confirmatory studies and Peter Libby added his landmark article Molecular Bases of the Acute Coronary Syndromes the same year. The evidence was crystal clear even then. Opening arteries does not prevent heart attack. Optimal medical therapy was effective in improving the health of the entire arterial system then and it is much better now. We understand the molecular biology that makes it so effective. Join me and other stakeholders in finally closing the chasm between knowledge and practice.