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Guidelines & Personalized MedicineFriends or Enemies
Prof. Yehonatan Sharabi, MD, FAHA
Director, Hypertension Unit
Immediate past president, Israeli Society of Hypertension,
Sheba Medical Center, Tel Hashomer
Tel Aviv University
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Figure 4
The Lancet 2018 392, 2052-2090DOI: (10.1016/S0140-6736(18)31694-5)
Leading 20 causes of YLLs globally in 2016 and 2040 by rank order
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Figure 4
The Lancet 2018 392, 2052-2090DOI: (10.1016/S0140-6736(18)31694-5) Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC
BY 4.0 license Terms and Conditions
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Figure 6
The Lancet 2018 392, 2052-2090DOI: (10.1016/S0140-6736(18)31694-5)
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Figure 6
The Lancet 2018 392, 2052-2090DOI: (10.1016/S0140-6736(18)31694-5) Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC
BY 4.0 license Terms and Conditions
WHO: “high blood pressure – No 1 contributor for preventable death worldwide”
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Mills KT, Circulation, 2016:
We are doing better but can do much better…
1995 2015
Awareness 58% 67%
Treatment 44% 55%
Control 18% 28%
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Why?
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Eyal Zimlichman MD, MSc8
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Solution: structured protocols?
• Protocol based treatment
– ACS
– Decompensated HF
– Pneumonia
• Chronic conditions?
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Clinical Practice Guidelines
12
“Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”Purposes:
• standardization of medical care
• Reduce discrepancies
• Improve outcome
• Reduce costs
* Institute of Medicine. Guidelines for clinical practice. 1990
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2018 ESC/ESH Guidelines for the managementof arterial hypertension
• 89 pages
• 33 tables
• 629 references
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The quest to clinically significant treatment:
Penicillin to pneumonia…
• Tilghman CR, Finland M,Arch Intern Med, 1937
• Observation
• N= dozens – hundreds
• Effect on mortality: -85%
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The quest for statistically significant treatments…
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𝑥
𝑁≫ 𝑃𝑣𝑎𝑙𝑢𝑒
The quest to P<0.05…
N P
The quest for statistically significant treatments…
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The quest for statistically significant treatments…
• Large clinical trials THOUSANDS
• Examples:• PROGRESS N=6105
• ADVANCE N=11000
• HYVET N=3845
• LIFE N=9193
• SCOPE N=4964
• ASCOT N=19257
• ACCOMPLISH N=10995
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The quest for statistically significant treatments…
• Metanalyses of HUNDREDS OF THOUSANDS
• Examples from ESH guidelines on how to treat your patient:
• Thomopoulos et al N=247,006
• Emdin et al N=100,354
• Ettehad et al N=613,815
Published in highly ranked journals
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Small step to mankind, Giant leap to CV…
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The quest for statistically significant treatments…
• Databases – MILLIONS !!
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Old school statistics applied on huge populations
Where is my patient? An average of all?
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Patients differ from each other
• Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike ...
• If it were not for the great variability among individuals, medicine might as well be a science and not an art
Sir William Osler
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34 y/o black female 52 y/o Caucasian male
Patients differ from each other
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Meta-regression analyses assessing the relationship between the hypertension cure rate
after PTRA and mean age, publication year.
Trinquart L et al. Hypertension 2010;56:525-532
Copyright © American Heart Association
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PERSONALIZED MEDICINE
Personalized medicine is a model that proposes the customization of healthcare, with decisions and practices being tailored to the individual patient.
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Basic data analytics: focus on one factor
• LIFE study – LVH
• PROGRESS – post CVA
• RENAAL - CKD
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Advanced data analytics: multiple factors modeling
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Modeling in medicine: current generation – scoring systems
• Atrial fibrillation and anticoagulants
– From yes/no to ChadsVasc score
• Statins in primary prevention
– From LDL levels to ESC/AHA risk score
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Future modeling: BIG DATA
Big data is a broad term for data sets so large or complex that traditional data processing applications are inadequate.
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Big data enables machine learning
Machine Learning and Prediction in Medicine
Chen et al, NEJM, June 2017:
• Machine-learning methods are particularly suited to predictions based on existing data
• Machine-learning algorithms can improve the accuracy of prediction over the use of conventional regression models by capturing complex, nonlinear relationships in the data
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• Genomics
• Epigenomics
• Pharmacogenomics
• Proteomics
• Metabolomics
• Microbiotomics
• Omics, Omics, Omics…
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35Wearable into Health Predictor
MACHINE LEARNINGSMARTPHONESENSORS & DEVICES STORAGE
24/7 Continuous - not sample diagnostic
MicrosoftJawboneGoogleSamsung
BandManage
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RCT Vs Big Data analytics
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38ר איל צימליכמן"ד
Children’s Hospital, BostonSCAMPS – Standardized Clinical Assessment and Management Plan
Guidelines – next generation
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Guidelines & Personalized Medicinecan be friends
• Guidelines, with its limitations, provides framework
• Guidelines should be followed NOT religiously
• Physicians should be comfortable to personalize treatment
• Clinical experience
• Experts guidance
• Common sense
• Modern technology would assist us in the near future
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Overview of the
meeting
Patient Centered Meeting is about translating the wealth of data to clinical practice
Case based learning
Different pateint prototypes from real world
A journey from the very beginning, through the management of a chronic disease to complex challenging cases
Motivational interview – how to make it happen
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THANK YOU AND WELCOME TO PCM !