Scientific evidence underlying the ACC/AHA clinical practice guidelines.

Tricoci, Pierluigi

doi:10.1001/jama.2009.205

Cited by 908Clinical practice guidelines implementationHealth Sciences Research and EducationCoronary Interventions and Diagnostics

Scientific evidence underlying the ACC/AHA clinical practice guidelines.

Tricoci, Pierluigi·2009·JAMA

DOI 10.1001/jama.2009.205

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Abstract

CONTEXT: The joint cardiovascular practice guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) have become important documents for guiding cardiology practice and establishing benchmarks for quality of care. OBJECTIVE: To describe the evolution of recommendations in ACC/AHA cardiovascular guidelines and the distribution of recommendations across classes of recommendations and levels of evidence. DATA SOURCES AND STUDY SELECTION: Data from all ACC/AHA practice guidelines issued from 1984 to September 2008 were abstracted by personnel in the ACC Science and Quality Division. Fifty-three guidelines on 22 topics, including a total of 7196 recommendations, were abstracted. DATA EXTRACTION: The number of recommendations and the distribution of classes of recommendation (I, II, and III) and levels of evidence (A, B, and C) were determined. The subset of guidelines that were current as of September 2008 was evaluated to describe changes in recommendations between the first and current versions as well as patterns in levels of evidence used in the current versions. RESULTS: Among guidelines with at least 1 revision or update by September 2008, the number of recommendations increased from 1330 to 1973 (+48%) from the first to the current version, with the largest increase observed in use of class II recommendations. Considering the 16 current guidelines reporting levels of evidence, only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C. Level of evidence significantly varies across categories of guidelines (disease, intervention, or diagnostic) and across individual guidelines. Recommendations with level of evidence A are mostly concentrated in class I, but only 245 of 1305 class I recommendations have level of evidence A (median, 19%). CONCLUSIONS: Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing. These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived.

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In a 2009 review of ACC/AHA guidelines, 11% of recommendations were classified as LOE A.
“In a review of the ACC/AHA clinical practice guidelines from 2009, only 11% of recommendations were classified as LOE A. 5”
From Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 (2019) · cites this paper as [5]
In 2009, Tricoci et al found that 12% of ACC/AHA guideline recommendations were LOE A, including 19% of class I recommendations.
“At that time, 12% of guideline recommendations were classified as LOE A, including 19% of class I recommendations.”
From Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 (2019) · cites this paper as [5]
In 6 guideline documents, Tricoci et al found minimal increases in LOE A recommendations compared with LOE B and C.
“in these 6 guideline documents, they found minimal increases in LOE A recommendations compared with LOE B and C.”
From Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 (2019) · cites this paper as [5]

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Authors: Tricoci, P.
Affiliations: Duke University (US)
Corresponding author: Tricoci, Pierluigi
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2009-02-25
Volume: 301
Issue: 8
Pages: 831
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.2009.205
OpenAlex: W2077033046
Cited by: 908
References: 88
Citations by year: 2026: 9 · 2025: 11 · 2024: 24 · 2023: 26 · 2022: 19 · 2021: 32 · 2020: 42 · 2019: 48 · 2018: 30 · 2017: 54 · 2016: 60 · 2015: 87 · 2014: 63 · 2013: 80 · 2012: 96
FWCI: 107.90
Type: journal article
Language: en
Open access: closed
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion)
Funders: Agency for Healthcare Research and Quality (U18 HS010548)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
Keywords: cardiovascular guidelines, level of evidence, guideline revision, evidence base, expert opinion, guideline development
MeSH terms: Cardiology, Cardiovascular Diseases, Humans, Quality of Health Care, Societies, Medical, United States, Practice Guidelines as Topic, Evidence-Based Medicine

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