Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Dec;26(18):1944-1952.
doi: 10.1177/2047487319868540. Epub 2019 Aug 14.

A systematic breakdown of the levels of evidence supporting the European Society of Cardiology guidelines

Wouter B van Dijk  1 , Diederick E Grobbee  1 , Martine C de Vries  2 , Rolf H H Groenwold  3 , Rieke van der Graaf  4 , Ewoud Schuit  1   5
Affiliations

A systematic breakdown of the levels of evidence supporting the European Society of Cardiology guidelines

Wouter B van Dijk et al. Eur J Prev Cardiol. 2019 Dec.

Abstract

Aims: Reviews of clinical practice guidelines have repeatedly concluded that only a minority of guideline recommendations are supported by high-quality evidence from randomised controlled trials. The aim of this study is to evaluate whether these findings apply to the whole cardiovascular evidence base or specific recommendation types and actions.

Methods: All recommendations from current European Society of Cardiology guidelines were extracted with their class (I, treatment is beneficial; II, treatment is possibly beneficial; III, treatment is harmful) and level of evidence (A, multiple randomised controlled trials/meta-analyses; B, single randomised controlled trials/large observational studies; C, expert opinion/small studies). Recommendations were categorised by type (therapeutic, diagnostic, other) and actions (e.g. pharmaceutical intervention/non-invasive imaging/test).

Results: In total, 3531 recommendations (median 128, interquartile range 108-150) were extracted from 27 guidelines. Therapeutic recommendations comprised 2545 (72.1%) recommendations, 411 (16.1%) were supported by level of evidence A, 833 (32.7%) by B and 1301 (51.1%) by C. Class I/III (should/should not) recommendations on minimally invasive interventions were most supported by level of evidence A (55/183, 30.1%) (B [70/183, 38.3%], C [58/183, 31.7%]), while class I/III recommendations on open surgical interventions were least supported by level of evidence A (15/164, 9.1%) (B [34/164, 20.7%], C [115/164, 70.1%]). Of all (831, 23.5%) diagnostic recommendations, just 44/503 (8.7%) class I/III recommendations were supported by level of evidence A (B (125/503, 24.9%), C (334/503, 66.4%)).

Conclusion: Evidence levels supporting European Society of Cardiology guideline recommendations differ widely between recommendation types and actions. Attributing to this variability are different evidence requirements, therapeutic/diagnostic recommendations, different feasibility levels for trials (e.g. open surgical/pharmacological) and many off-topic/policy recommendations based on expert opinion.

Keywords: Clinical practice guidelines; European Society of Cardiology; cardiovascular evidence base; guideline recommendations; levels of evidence.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Overall proportions of recommendation classes and levels of evidence.
Figure 2.
Figure 2.
Proportions of types of recommendations by classes and evidence levels.
Figure 3.
Figure 3.
Recommendations of modes of action and evidence levels by classes: (a) therapeutic; (b) diagnostic.
Figure 4.
Figure 4.
Recommendations by subspecialty, type and level of evidence.
See this image and copyright information in PMC

Comment in

References

    1. American College of Cardiology. Real-world evidence: perceptions of cardiologists. Cardiol Mag 2018; 47: 28–29.
    1. Vaucher J, Marques-Vidal P, Waeber G, et al. Population impact of the 2017 ACC/AHA guidelines compared with the 2013 ESH/ESC guidelines for hypertension management. Eur J Prev Cardiol 2018; 25: 1111–1113. - PubMed
    1. Pencina MJ, Navar-Boggan AM, D'Agostino RB, et al. Application of New Cholesterol Guidelines to a Population-Based Sample. N Engl J Med 2014; 370: 1422–1431. - PubMed
    1. Fanaroff AC, Califf RM, Windecker S, et al. Levels of evidence supporting American College of Cardiology/American Heart Association and European Society of Cardiology guidelines, 2008–2018. JAMA 2019; 27715: 1069–1080. - PMC - PubMed
    1. Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009; 301: 831–841. - PubMed

Publication types