Condition or domain being studied
We will be studying all guidelines focusing on cardiovascular conditions developed and published by the ESC, ACC and AHA over a 10-year time interval.
The ESC, ACC and AHA guidelines are considered to be amongst the most important cardiovascular disease guidelines in medicine (Tantawy 2023, Tricoci 2009, Faranoff 2019). These have been published since the 80s (Frye 1984) and 90s (Pyörälä 1994), and have become so popular that they are used by physicians around the world (Tantawy 2023, Tricoci 2009, Faranoff 2019).
Guidelines should have a clearly defined methodology, and by definition should be informed by systematic reviews of evidence with assessment of the benefits and harm of the available treatment and management options (6). This seems to be practice for governmental or intergovernmental organizations like the National Institute for Health and Care Excellence (WHO 2014) in the UK, or the World Health Organization (NICE 2022) with publicly available and published methodology (WHO 2014, NICE 2022).
Guidelines are composed of recommendations. For each recommendation there is a Class of Recommendation assigned by the Guideline writing committee, and a Level of Evidence (the existing clinical data, if any, supporting the recommendation). The classification used by the ESC, ACC and AHA overlaps, with four classes of recommendation and three different levels of evidence (Ponikowski 2016):Class I: conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.Class II: conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.Class IIa: weight of evidence/opinion is in favor of usefulness/efficacy.Class IIb: usefulness/efficacy is less well established by evidence/opinion.Class III: conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.Level A:recommendation based on evidence from multiple randomized trials or meta-analyses.Level B:recommendation based on evidence from a single randomized trial or non-randomized studies.Level C:recommendation based on expert opinion, case studies, or standards of care.
Recent ACC/AHA guidelines (Isselbacher 2022) added extra details and sub-divisions to Class or recommendation (Class I – Strong; Class IIa – Moderate; Class IIb – Weak; Class III - No Benefit/Moderate; Class III – Harm/Strong) and Level of Evidence (Level B – Randomized; Level B – Nonrandomized; Level C-LD- limited data; Level C-EO – expert opinion).
1. Tantawy M, Marwan M, Hussien S, Tamara A, Mosaad S. The scale of scientific evidence behind the current ESC clinical guidelines. IJC Heart & Vasculature. 2023;45:101175.
2. Tricoci P, Allen JM, Kramer JM. Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines. JAMA. 2009;301:831-841.
3. Fanaroff AC, Califf RM, Windecker S, Smith SC, Lopes RD. Levels of evidence supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008–2018. JAMA. 2019;321:1069–1080.
4. Frye RL, Collins JJ, DeSanctis RW, Dodge HT, Dreifus LS, Fisch C, Geths LS, Gillette PC, Parsonnet V, Reeves J, et al. Guidelines for permanent cardiac pacemaker implantation, May 1984: a report of the Joint American College of Cardiology/American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Pacemaker Implantation). Circulation. 1984;70:331A-339A.
5. Pyörälä K, De Backer G, Graham I, Poole-Wilson P, Wood D. Prevention of coronary heart disease in clinical practice. Recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J. 1994;15:1300-31.
9. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P; ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–200.
10. Isselbacher EM, Preventza O, Hamilton Black 3rdJ, Augoustides JG, Beck AW, Bolen MA, Braverman AC, BrayBE , Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda Jr A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, SchermerhornML, Singleton Times S, Tseng EE, Wang GJ, Woo UJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146:e334-e482.