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June 28, 1995

Heart Failure Practice Guidelines: Guidance, Not Proscription

Author Affiliations

New England Medical Center Boston, Mass

JAMA. 1995;273(24):1904-1905. doi:10.1001/jama.1995.03520480022024

To the Editor.  —Dr Parmley1 recently commented on our recommendations for medical management,2 based on the published clinical practice guideline for heart failure.3I largely agree with Parmley's delineation of the value and limitations of such guidelines. These opinions are my own.Guidelines are intended to reduce gaps between scientific knowledge and clinical practice, which may be particularly prevalent among primary care physicians who must follow advances in numerous specialties. As Parmley states, the value of guidelines stems from the authors' having "carefully evaluated the world's literature... as the basis for decision making." So much for the easy part. The hard part is implementing guidelines prudently.It is tempting to transform guideline recommendations into dictum, assigning penalties or rewards based on compliance, but one must choose between the following two perceptions of guidelines: (1) they are declarations of standard care that require rigid adherence, or (2) they

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