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. 2023 Oct;10(5):3019-3027.
doi: 10.1002/ehf2.14459. Epub 2023 Aug 7.

Temporal trends in evidence supporting therapeutic interventions in heart failure and other European Society of Cardiology guidelines

Marco Canepa  1   2 , Vincenzo De Marzo  2 , Pietro Ameri  1   2 , Roberto Ferrari  3   4 , Luigi Tavazzi  5 , Claudio Rapezzi  4   5 , Italo Porto  1   2 , Aldo Pietro Maggioni  5   6
Affiliations

Temporal trends in evidence supporting therapeutic interventions in heart failure and other European Society of Cardiology guidelines

Marco Canepa et al. ESC Heart Fail. 2023 Oct.

Abstract

Aims: This study aimed to determine whether any change occurred over time in level of evidence (LoE) of therapeutic interventions supporting heart failure (HF) and other European Society of Cardiology guideline recommendations.

Methods and results: We selected topics with at least three documents released between 2008 and April 2022. Classes of recommendations (CoR) and supporting LoE related to therapeutic interventions within each document were collected and compared over time. A total of 1822 recommendations from 18 documents on 6 topics [median number per document = 112, 867 (48%) CoR I] were included in the analysis. There was a trend towards a reduction over time in the percentage of CoR I in HF (46-36-34%), non-ST elevation myocardial infarction (NSTEMI; 78-58-54%), and pulmonary embolism (PE; 65-50-39%) guidelines, with a decrease in the total number of recommendations for HF only. Percentage of CoR I was stable over time around 40% for valvular heart disease (VHD) and atrial fibrillation (AF), and around 60% for cardiovascular prevention (CVP), with an increase in the total number of recommendations for VHD and CVP and a decrease for AF. Among CoR I, 319 (37%) were supported by LoE A, with a decrease over time for HF (56-46-42%), an increase for NSTEMI (29-38-48%) and AF (28-31-36%), a bimodal distribution for PE and CVP, and a lack for VHD.

Conclusions: LoE supporting therapeutic recommendations in contemporary European guidelines is generally low. Physicians should be aware of these limitations, and scientific societies promote a greater understanding of their significance and drive future research directions.

Keywords: Guideline; Heart failure; Level of evidence; Randomized controlled trial; Temporal trend.

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Conflict of interest statement

V.D.M. has received speaker and/or advisor fees from AstraZeneca, Daiichi‐Sankyo, Bristol‐Myers Squibb, and Bayer, outside the present work. M.C. has received speaker and/or advisor fees from Pfizer, Alnylam, AstraZeneca, Sanofi e Sanofi Genzyme, Novartis, and Vifor, outside the present work. P.A. has received speaker and/or advisor fees from AstraZeneca, Boehringer Ingelheim, Bayer, Novartis, and Vifor, outside the present work. R.F. has received personal fees from Merck Serono, Boehringer Ingelheim, Sun Pharma, Lupin, Doc Generici, Pfizer, and SPA Prodotti Antibiotici, outside the present work. He is a director of Art Research and Science S.r.l (A.R.S.1) and Scientific Director of Medical Trial Analysis. C.R. declares no conflicts of interest related to the present work. I.P. has received speaker and/or advisor fees from Biotronik, Abiomed, Terumo, Amgen, Daiichi‐Sankyo, AstraZeneca, Bayer, Medtronic, Philips, and Abbott, outside the present work. A.P.M. has received personal fees from Bayer, AstraZeneca, and Novartis, outside the present work, for the participation in committees of clinical studies.

Figures

Figure 1
Figure 1
Prevalence of class I recommendations over time. AF, atrial fibrillation; CVP, cardiovascular prevention; HF, heart failure; n, number of class I recommendations over total recommendations in each guideline document; NSTEMI, non‐ST elevation myocardial infarction; PE, pulmonary embolism; VHD, valvular heart disease.
Figure 2
Figure 2
Distribution of level of evidence among class I recommendations over time. AF, atrial fibrillation; CVP, cardiovascular prevention; HF, heart failure; n, number of level of evidence A recommendations over class I recommendations in each guideline document; NSTEMI, non‐ST elevation myocardial infarction; PE, pulmonary embolism; VHD, valvular heart disease. The total number of class I recommendations for each guideline document is listed in Figure 1 .
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