Evidence Based Medicine vs. Expert Consensus in Medical Guidelines: An Artificial Conflict

Recommendations for objective cardiovascular assessment to inform clinical exercise prescription: An Exercise Physiologist and Physiotherapist expert consensus

OBJECTIVES

Exercise is beneficial in managing cardiovascular health. Objective assessments of cardiovascular function assist in identifying the presence or absence of exertional symptoms, and functional and physiological thresholds necessary to inform safe and effective exercise programmes. This study aimed to generate expert consensus on assessments of cardiovascular function to support clinical decision-making for professionals providing clinical exercise services.

DESIGN

Three-round e-Delphi.

METHODS

Expert Exercise Physiologists and Physiotherapists were recruited to participate in an e-Delphi. Experts were asked to list all objective cardiovascular assessments deemed necessary to inform safe and effective exercise prescription. In subsequent e-Delphi rounds, experts rated the importance of each item, provided a rationale to support their assertions, and reconsidered others' ratings and rationale to shift or reaffirm their position. These results were then translated into a clinical guidance document by the authors in consultation with a Cardiologist and an experienced Exercise Physiologist with expertise in cardiovascular assessment.

RESULTS

Thirty-one experts participated in the e-Delphi and fourteen participants completed all three rounds. Forty objective assessments were initially suggested. Six items reached consensus by the end of Round 2 (resting and exercise heart rate, resting, exercise, and recovery blood pressure, and peak exercise-induced rating of perceived exertion). One additional item reached consensus in Round 3 (exercise oxygen saturation).

CONCLUSIONS

In the absence of research evidence, the collective experience and insights of an expert panel can inform an evidence gap. Further research is required to determine the feasibility of implementing these seven assessments in practice where CV assessment is indicated.

Lack of Cited Evidence Underpinning Recommendations for Objective Assessment of Cardiovascular Function to Inform Exercise Prescription: A Systematic Review

BACKGROUND

The effectiveness of exercise in managing cardiovascular (CV) health and function is well established. Less clear is the process for optimising the safety and efficacy of an intervention, particularly how objective assessments might inform this process.

OBJECTIVE

The aim of this review was to investigate the cited evidence underpinning recommendations for assessing CV function to inform the safe and effective prescription of exercise in populations with established CV disease, as published in documents to guide practice authored by prominent organisations in cardiology and sports medicine.

METHODS

A systematic review of position statements and guiding documents on exercise prescription for CV health was conducted. Included documents were published between 1997 and 2016.

RESULTS

Following removal of duplicates, 3158 documents were considered, with full-text screening required for 334. Twenty-seven documents were included which provided 106 individual recommendations for specific objective assessments. Of the total number of recommendations, 60% had no accompanying citation and 28% of recommendations provided citations that did not directly support the statement made. Additionally, 52% of included documents did not state the methods of document development. That is, it was not clear if there was a literature review and/or expert consensus that was used to form recommendations included within.

CONCLUSION

Almost no cited evidence underpinning the extracted recommendations from the included guiding documents, nor any acknowledgement of this deficiency was established. There were limited explanations found for the methods involved in developing such guiding documents.