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Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organizations-European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific Task Force. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements. The rationale for an active approach to the prevention of cardiovascular diseases (CVD) is …

We report on the 15-year prognosis of 720 male and 246 female 28-day survivors of a first myocardial infarction or episode of unstable angina who were aged under 60 years at the time of admission to the study. Women were on average 1.9 years older than men, had higher cholesterol levels, a higher prevalence of hypertension and angina prior to admission and a higher proportion were lifetime non-smokers. Women were more likely to be admitted with unstable angina rather than infarction. When adjusted for age, smoking status, angina, hypertension and the difference in prevalence of infarction, women had a relative risk of death of 1.054 in a 15-year life table mortality analysis. Prognostic differences between the sexes reported may be the result of failure to allow for differences in other prognostic factors.

We welcome the contribution from Drs Assman, Cullen, Hense and Schulte. The issues which they raise are among the many which were debated at the SCORE project workshops, and, indeed, we gratefully acknowledge the participation of Drs Cullen and Schulte in these workshops. Their views are given added significance as three of the four authors have themselves authored guidelines for prevention of coronary heart disease. Their first comment concerns the disadvantages of calculating total cardiovascular risk rather than risk of coronary heart disease alone. We would like to reiterate our concern that by concentrating on coronary heart disease alone, the true health consequences of the person’s risk factors will be misrepresented. Prevention …

This is a study of the relationship between the site of infarction and both risk factors and in-hospital outcome in 745 consecutive patients admitted with a first myocardial infarction. Patients with anterior infarctions were significantly more likely never to have smoked than patients with inferior infarctions. They had a higher prevalence of hypertension and a higher mean cholesterol level. In hospital prognosis was worse in anterior infarctions, with significantly higher rates of death and complications. Atrioventricular blocks were more common in inferior infarctions. Non-Q-wave infarctions had a lower incidence of complications than Q-wave infarctions. There was no difference in risk factor levels between Q-wave and non-Q-wave infarctions. Anterior and inferior infarctions were of similar size. Non-Q-wave infarctions were significantly smaller. A logistic regression showed a negative relationship between in-hospital mortality and smoking, and a positive one with peak cardiac enzyme levels. Any effect of site of infarction on mortality was eliminated when corrected for these factors. Our data indicate that the adverse prognosis associated with anterior myocardial infarction is related to differences in aetiology rather than to infarction size.

The St Vincent's Cardiac Rehabilitation Programme is based on an out-patient non-institutionalized service with long-term follow-up and home-based exercise programmes. Return to work rates of more than 90% in the 1960s and 1970s were reported but these rates have not been sustained in the past seven years. These secular changes in return to work rates are attributed to recent changes in the social and economic climate in Ireland. Medical, social, demographic, and psychological factors which may influence successful return to work were studied. The previously employed, young patients and those in the higher social groups, patients with less severe attacks and those free from post-infarction angina, reported the best return to work rates. Reasons for failure to return to work could be attributed equally to organic and functional causes. Factors affecting secondary preventive measures, including smoking cessation, desirable dietary and weight changes, and aerobic exercise programmes, were also studied. These changes were best achieved by young patients, white-collar workers, the better educated and urban dwellers. It is concluded that informal out-patient rehabilitation programmes aimed at early return to a normal life, active secondary prevention measures and home-based exercise programmes, are effective and safe in the great majority of patients recovering from myocardial infarction and coronary bypass surgery.